Ob-Gyn Coding Alert

Ob/gyns who bill inpatient hospital visits as concurrent care should emphasize the condition they are treating, which may not be the same reason the patient was admitted to the hospital, to avoid denials.

Concurrent care occurs when two or more physicians treat the same patient on the same day. The patient's condition must warrant the services of multiple physicians, which can be proven by each physician using different diagnoses, says Jean Ryan-Niemackl, LPN, CPC, compliance analyst for QuadraMed, a multispecialty coding consulting firm in Fargo, N.D. "Usually, the physicians are of different specialties. But in the case of consultations, the physicians' specialties may be the same."

For example, an ob/gyn admits a diabetic patient to the hospital because of severe pelvic inflammatory disease (614.3). The inflammatory disease has exacerbated the patient's diabetes (250.0x). The ob/gyn treats the patient's pelvic inflammation, while an internist or endocrinologist treats the diabetes. Because the ob/gyn admitted the patient to the hospital, she would report one of the initial hospital care codes (99221-99223), while the internist/endocrinologist would code either a consultation or a subsequent hospital visit, depending on the nature of the request, Ryan-Niemackl says. Both physicians would be able to bill subsequent hospital care codes (99231-99233) to cover the continuing evaluation and management of the patient.

The key to obtaining maximum ethical reimbursement for concurrent care is to stress the different conditions (diagnoses) the different physicians are treating. Ob/gyns should link their services to the condition they are personally treating. In the example above where the ob/gyn and the internist are providing concurrent care, the ob/gyn should list severe pelvic inflammatory disease (614.3) as the primary diagnosis code. Although the ob/gyn is considering the diabetes in her medical decision-making, she should not list the code "Not because it isn't the most correct way to code, but because of the multitude of problems it causes with the claim," Ryan-Niemackl says.

The internist should list diabetes as the primary diagnosis on his claim. If each physician reports a separate diagnosis, it supports the medical necessity of both physicians attending the patient on the same day and prevents payers from rejecting the claim, says Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa.

Ob/gyns must also be able to document that their services were medically necessary. Stopping by the patient's room to see how she is doing or for a social visit does not constitute concurrent care. The same components of all E/M visits history, examination and medical decision-making or counseling/coordination of care time must be part of the concurrent care visit.

In addition, the patient's medical record should detail the specific services the ob/gyn provided. It should reflect the physician's active involvement with the patient, and there should be sufficient documentation to determine the role each physician played.

You should also distinguish between concurrent care and a consultation because inpatient consultations (99251-99255) have higher relative values than the corresponding subsequent hospital care codes, according to the 2002 Physician Fee Schedule. Medicare and CPT have the same three basic criteria for a consultation:

1. A request for a consultation from the patient's physician must be recorded in the patient's medical record

2. The consultant must review the patient's condition

3. The consulting physician must provide a written report of his or her findings to the requesting physician. This is satisfied with the progress note written in the inpatient chart because this chart is a shared medical record among all the physician specialists involved in the patient's care, Ryan-Niemackl points out.

A consulting ob/gyn may initiate diagnostic and/or therapeutic services at the time of the evaluation or during a subsequent visit, and the service will be considered a consultation because no transfer of care occurs at the time of the request for an evaluation.

For example, an internist in the hospital requests an ob/gyn's opinion regarding a kidney transplant patient who has developed uterine bleeding. The ob/gyn reviews the patient's condition and issues a report to the internist detailing diagnosis and treatment options. After reviewing the ob/gyn's report, the internist asks the ob/gyn to manage the patient's uterine bleeding.

To report the ob/gyn's services, you would bill an initial inpatient consultation (e.g., 99255, Initial inpatient consultation for a new or established patient ) linked to the uterine bleeding diagnosis (626.9), Revel says. Any subsequent E/M services the ob/gyn provides in treating the patient should be reported with subsequent hospital care codes (99231-99233), she adds.

Ob/gyn coders may get confused about whether a transfer of care has occurred because ob/gyns are often asked to manage a portion of the patient's care after the consultation. The ob/gyn should ask what the intent is in seeing the patient. If the physician requesting the consultation only wants to hear an opinion from the ob/gyn, then it is a consultation. (See the box below for a list of questions that help to delineate whether a visit is a consultation or a referral.)