Ob-Gyn Coding Alert

You may have more options than you think


When dividing ob-gyns' roles with split antepartum care, the key is counting the visits, coding experts say.
 
When your obstetrician shares maternity care with a physician outside a group practice, you will have to abandon the global codes (59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care; 59510, Routine obstetric care including antepartum care, cesarean delivery, and postpartum care; 59610, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery; and 59618, Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery).
 
CPT states that antepartum care includes monthly visits up to 28 weeks gestation, biweekly visits up to 36 weeks gestation, and weekly visits until delivery, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. Ob services include obtaining the patient's history, performing a physical exam, recording vital statistics, and doing other examinations necessary to provide safe and appropriate care for the mother and fetus.
 
"When patients change providers during the course of their pregnancies, the question for ob coders becomes: What options do we have in accurately coding and reporting the services provided?" Mulholland adds.

3 Choices for Coding Antepartum Care

If your ob-gyn only provides antepartum care, you have three potential ways to report his services.
 
Option 1: "If the patient had a total of one to three antepartum visits, report the appropriate level of E/M service for each visit with the date of service that the visit occurred and the diagnosis for why the patient was seen," states the American College of Obstetricians and Gynecologists (ACOG). For example, if the doctor sees an ob patient twice before she moves to a different area, you would report the appropriate E/M code (99201-99215) for each visit with V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy).
 
Option 2: On the other hand, if the ob-gyn sees the patient four to six times before she leaves his care, you will report 59425 (Antepartum care only; 4-6 visits), ACOG states. Because 59425 represents the total work involved with all of the visits, you should submit it only once with a "1" in the units box of the CMS-1500 claim form. Also, be sure to include the "to" and "from" dates during which the services occurred.
 
Enter the first prenatal visit in box 15 and only enter the last visit the patient was seen for prenatal care in box 25a, says Brenda Dombkowski, CPC, a coding specialist at Obstetric-Gynecology & Infertility Group in Cheshire, Conn. "I was receiving rejections due to file limit if I entered a duration of dates. The claim software was looking at the first date in box 25a and not the 'from' date."
 
Option 3: If your physician provides seven or more antepartum visits, you should report 59426 (... 7 or more visits), according to ACOG. As with 59425, you should report 59426 only once and place a "1" in the units box. You should also record the "to" and "from" dates for the services your ob-gyn provided.
 
To avoid reimbursement hassles, be sure to ask your carriers how they want multiple antepartum visits coded, Mulholland says. "Each carrier may have different requirements for reporting services - especially those services that vary from the usual - and physicians must know how to correctly report the services they provide to be in compliance, as well as receive appropriate reimbursement for the services provided."
 
Some payers may allow you to bill an E/M service instead of the antepartum visit package codes. And reporting individual visits allows you to get paid at the time of service rather than waiting until you complete the required number of visits and billing the corresponding code.

Patient Transfer May Mean Reporting the Global

When a patient transfers to your ob-gyn practice late in her pregnancy, your first task is to determine if she has received any antepartum care elsewhere, ACOG recommends. If she has received antepartum care from another physician, you will not be able to report the global ob code (59400, 59510, 59610 or 59618). Instead, you will have to report the antepartum care (59425-59426), delivery (59409-59410, 59514-59515, 59612-59614) and postpartum care (59430) separately. If the ob-gyn performs the delivery and postpartum care, CPT includes 59430 with the code for delivery with postpartum care.
 
The physician who provided the initial antepartum care will bill separately for his services. Consequently, if you bill the global in this case, you would be reporting some antepartum care that you did not perform.
 
On the other hand, if the patient did not receive any antepartum care before coming to your practice, you may be able to report the global code. The physician may perform all the global ob package components in a short time because CPT doesn't require a minimum number of antepartum visits to report this service. But some carriers do require an established number - usually 12-15 - of antepartum visits before you can submit the global ob code(s). If your ob-gyn performs substantially fewer visits than the payer normally requires for the global package, you may report the global ob code appended with modifier -52 (Reduced services).
 
"I usually check with the carrier concerning their policy on global maternity when the patient changes insurance or transfers to our practice during her pregnancy," Dombkowski says. "Some of our carriers request that we send the claim when the patient delivers as a global fee and enter the first prenatal visit in box 15. They will then prorate the global depending on the duration of care with us."