Ob-Gyn Coding Alert

Know what to do when ob-gyn performs c-section for twins

Coding deliveries isn't as easy as simply reporting a global code. Sometimes extenuating circumstances require you to choose from itemized delivery codes -- and use modifiers like 51, 59 and 22.

Read the following four scenarios and see if your answers match up with our experts- guidance.

1. Your Ob-Gyn Delivers for Unaffiliated Ob-Gyn

Scenario: A pregnant patient's regular ob-gyn is out of town when the patient goes into labor. Your ob-gyn, who is not affiliated with the regular ob-gyn, performs a normal delivery. How should you report this?

Answer: You should report the delivery according to how your ob-gyn performed it -- either vaginal (59409, Vaginal delivery only [with or without episiotomy and/or forceps]) or cesarean (59514, Cesarean delivery only), says Cassandra Walker McKibben, billing manager for Regional Obstetrical Consultants in Chattanooga, Tenn.

As for diagnoses, you should use 650 (Normal delivery) and V27.0 (Single liveborn), says Shawna Landstra, biller at Mansion Street Ob-Gyn in Marshall, Mich.

Keep in mind: -You should allow the patient's regular ob-gyn to bill for the antepartum visits. The delivery CPT code will include postpartum visits in the hospital if there are no complications,- as well as discharge, McKibben says. 

But if your ob-gyn provides all postpartum care services both in and out of the hospital, you should look to 59410 (... including postpartum care), says Cheryl Ortenzi, CPC, billing and compliance manager for BUOB/Gyn in Boston. Use V24.2 (Routine postpartum follow-up) for your supporting diagnosis, Landstra says.

2. What to Do When Nurse Delivers Instead

Scenario: The nurse delivers the baby because the ob-gyn is in the next room doing a procedure on another patient. How should you report this?

Answer: You can use a global code (such as 59400). You should probably add modifier 52 (Reduced services) to account for the fact that the ob-gyn wasn't present. Be sure to include information about which part of the process he did participate in, so you-ll lessen the impact of any fee reduction the payer might apply.

3. Master Multiple-Gestation Deliveries

Scenario A: One of your ob-gyn's regular patients is having twins, and your ob-gyn delivers them both vaginally. How should you report this?

Answer A: You should report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; multiple procedures) for the second, Ortenzi says.
 
-Modifier 51 on the second code is key for reimbursement,- says Shelley Bellm, CPC, coding manager for Colorado Mountain Medical in Vail, Colo.

Caution: -Some carriers require you to bill vaginal deliveries broken up into two separate codes with modifier 59 (Distinct procedural service) attached,- Landstra says. -Other payers will not pay anything additional for twin B when the delivery is vaginal,- Ortenzi says.

Nevertheless, your diagnoses will be 651.01 (Twin pregnancy; delivered, with or without mention of antepartum condition) and V27.2 (Twins, both liveborn).

Scenario B: The ob-gyn delivers the first baby vaginally but the second by cesarean. How should you report this?

Answer B: You should report 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care) for the second baby and 59409-51 for the first, Ortenzi says. Why: You should bill the cesarean first because 59510 has higher RVUs (relative value units). The RVU for 59409 is 22.01, and the RVU for 59510 is 49.72 -- a difference of about $1,050.

The diagnoses for the vaginal birth will include 651.01 and V27.2.

For the second twin born by cesarean, use additional ICD-9 codes to explain why the ob-gyn had to perform the c-section -- for example, malpresentation (652.6x, Multiple gestation with malpresentation of one fetus or more) -- and the outcome (such as V27.2).

Scenario C: The ob-gyn delivers both babies by c-section. How should you report this?

Answer C: When the doctor delivers all of the babies -- whether twins, triplets or more -- by cesarean, you should submit 59510-22. The reason you report only one code is that the ob-gyn is only making one incision, Landstra says.

Focus on this: Report 59510 with modifier 22 (Unusual procedural services) appended, Bellm says. Theob-gyn performed only one cesarean, but the modifier shows that the ob-gyn performed a significantly more difficult delivery due to the presence of multiple babies. -I always include a letter of explanation for modifier 22 and the reason why I am asking for higher reimbursement along with a copy of the operative report,- Bellm says.

Finally, for the diagnoses, include the reason for the cesarean, 651.01, and V27.2.

4. Check Your Complications Coding

Scenario: During a vaginal and/or cesarean delivery, the patient has a complication. How should you report this?

Answer: -For complications of pregnancy, the old rule -some are easy, some are hard- comes to mind,- Ortenzi says.

If the complication required extra work (such as a third- or fourth-degree repair, or uterine atony after cesarean), you should report the main procedure code (such as 59510) with modifier 22 appended, Bellm says. You should be able to explain the need for this modifier.

Also, -when the patient requires additional services such as extra visits, ultrasounds, and testing that are not included in the routine global ob package, we definitely bill those out,- Ortenzi says.

Heads up: -When billing for complications of the delivery, you want to make sure you are using diagnosis codes in the 641-677 series,- Bellm says. For example, you should report 648.91 (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium; other current conditions classifiable elsewhere; delivered, with or without mention of antepartum condition) with a secondary code describing the complication, McKibben says.

-ICD-9 codes and documentation are critical to maximize ethical reimbursement for these services,- Ortenzi says.