Ob-Gyn Coding Alert

During delivery, or when a patient delivers prematurely, a number of complications can arise. The most common ones sometimes require additional procedures, but mostly additional time, from the ob/gyn and attending staff. For many of these complications, the old labor-and-delivery adage "Some are easy, some are hard" rings true. There are ways to increase reimbursement ethically for other complications.

Prolonged labor, defined as active labor that continues more than 18 hours, is most common with first-time mothers. When labor lasts too long, a number of side effects can affect the outcome. The patient can become too exhausted to deliver vaginally, and both mother and fetus are at risk for complications. Typically, a physician will order intravenous fluids to prevent dehydration, then order oxytocin to augment labor contractions. If the cervix does not dilate despite uterine contractions, a cesarean section is usually performed.
 
The codes for prolonged labor are 662.0x (long labor, prolonged first stage), the time from the onset of labor through complete dilation of the cervix; 662.1x (prolonged labor, unspecified); and 662.2x (long labor, prolonged second stage), the time from complete dilation of the cervix through birth of the fetus. A fifth digit is required with these codes to indicate at what point during the pregnancy the complication arose, and if delivery was successful or not.
 
Assuming a scenario where oxytocin is administered and failed to result in labor, and a cesarean delivery is performed, the global code for the ob care package is 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care). The diagnostic code for the cesarean is 659.11 (failed medical or unspecified induction; failure of induction of labor by medical methods, such as oxytocic drugs [Pitocin]). Since the drug is provided by the hospital and will be part of the patient's bill, the ob/gyn does not charge for the drug. Also, in this scenario, the physician cannot bill separately for the IV infusion because it is normally started by hospital nursing staff. 

Labor Management More Than 24 Hours Is Billable

For cases of prolonged labor, coders and physicians should keep an eye on the clock. "Most labor-related in-hospital care rendered more than 24 hours prior to delivery is billable," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. "For cases where the patient is admitted in labor, or admitted so that labor can be induced, but there is no delivery for 24 hours, additional codes come into play."
 
Use a hospital admit code 99221-99223 (initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: ranging from a detailed to a comprehensive history, a detailed to comprehensive examination, and medical decision making that is straightforward or of low complexity to high complexity), with the code for admission linked to the reason for admission, which in this case is 658.33 (delayed delivery after artificial rupture of membranes; antepartum condition or complication).

Abnormal Presentation

The normal position for a fetus prior to delivery is vertex: head down, facing the mother's back, with chin to chest. But a number of malpositions can complicate labor and delivery. The risk of injuries to the uterus or birth canal and for abnormal labor is increased by abnormal presentations.
 
The ICD-9 category for malposition and malpresentation of a fetus (652.0x-652.9x) includes a number of scenarios, the most common of which is breech presentation (652.2x, breech presentation without mention of version). Some fetuses present with their buttocks or feet pointed down toward the birth canal (a frank, complete or incomplete/footling breech presentation). Though most breech positions are seen well before the due date and correct on their own, those that do not are at risk of injury and for a prolapsed umbilical cord (see below).
 
For breech-positioned fetuses that do not move on their own, physicians often attempt an external cephalic version in which the fetus is manually manipulated inside the uterus. External cephalic versions typically take place in the hospital, if an emergency cesarean is required. "Our physician has had to perform these manual 'turns' on occasion, particularly with multiple fetuses,'' says Leslie Davis, insurance specialist for Naples Women's Center in Naples, Fla.
    
The code for external cephalic version is 59412 (external cephalic version, with or without tocolysis [list in addition to code(s) for delivery]). External cephalic version is one of the few antepartum procedures directly related to pregnancy for which the ob/gyn can bill separately from the global package, and the code can be billed whether the version is successful or not. If unsuccessful, modifier -52 (reduced services) is added to  59412. If the version is successful, use 652.1x (breech or other malpresentation successfully converted to cephalic presentation). If it is unsuccessful, use 652.2x (breech presentation without mention of version). "Whether or not we get any additional reimbursement for the procedure is another story,'' Davis says.

Cephalopelvic disproportion occurs when the baby's head is too large to fit through the mother's pelvis, due to their relative sizes or because of malpositioning of the fetus. Cephalopelvic positioning (653.4x, fetopelvic disproportion) that does not correct by the time of delivery usually results in a cesarean delivery, with diagnostic code 660.0x (obstruction caused by malposition of fetus at onset of labor).
 

Umbilical cord prolapse (663.0x, prolapse of cord) describes the cord protruding from the birth canal before the fetus is delivered. Umbilical-cord compression (663.1x, 663.2x) occurs when the cord becomes wrapped around the fetus' neck or other body part. If not corrected, these complications can cause fetal death. They almost always result in an emergency cesarean.
  
In any of these cases, the physician cannot charge for any additional procedures other than the difference between the cost of a global package with vaginal birth and a global package with cesarean. The cost differs from carrier to carrier, but a cesarean reimburses higher than a vaginal delivery.

In the code definitions for global care, the word "routine" is an important distinction. Anything considered outside of "routine" care is also outside of global care. For complications of delivery requiring extra work, and when no CPT code is available to describe that work, modifier -22 (unusual procedural services) is a coder's best line of offense. When a physician spends extra time and management with a patient, attach modifier -22 to the global ob code.
 
"The modifier indicates a level of service greater than 'the norm,'" Callaway says, "but physicians will still have to explain the extra work that was done." The modifier requires a detailed note from the obstetrician that explains rule "ins" and rule "outs" and describes the level of risk to patient and fetus. This, coupled with the ICD-9 codes detailing the condition, will bolster the case for reimbursement.