Ob-Gyn Coding Alert

Your practice may be losing money by using codes for single pregnancies when coding multiple gestation procedures.

The good news is that CPT offers a way to correctly code for diagnostic procedures performed on twins. The bad news is that many payers do not recognize the additional work involved with twins. Both challenges can be overcome with correct coding and communication with the payer, explains Melanie Witt, RN, CPC, MA, program manager for Coding and Nomenclature at the American College of Obstetricians and Gynecologists.

The obstetrician or maternal fetal specialist may spend more time supervising a twin pregnancy than a single one, and may need to perform diagnostic tests to monitor the progress of the two babies. Often, the physician is not being reimbursed appropriately because of reimbursement policies or coding mistakes.

For example, CPT has a code for a complete ultrasound for multiple gestation (76810); other services are reported with codes designed for a single pregnancy. One reader in Virginia recently asked if it was wishful thinking to be able to bill for two fetal non-stress tests (NST) or two biophysical profiles (BPP) when there are twins.

Because the code for a non-stress test (NST), 59025, describes only the service performed on a single fetus, when twins are present, two non-stress tests are performed and documentedone for each fetus. There are three coding options in this case:

1. Bill each NST separately. The most accurate way to bill for NSTs performed on twins is to bill each NST separately, Witt explains. This can be done in one of two ways. The single-line approach would be to indicate a quantity of two for the code 59025 (linked to the diagnosis of why the NST was medically indicated and the presence of twins, 651.03). The two-line approach would include listing the code 59025 twice, but the payer may require a modifier -51 (multiple procedures) to be added to the second code because of discounting on the second procedure. This would be standard coding for any surgical procedure, as an NST is classified in the CPT book.

2. Modifier -22. An additional option may be to attach a modifier -22 for unusual and complicated services, says Barbara L. Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ. She notes that attaching a cover letter to the claim to explain why additional reimbursement is being requested gives you the opportunity to fully explain the service up front, which will help alleviate denials.

3. Biophysical profile. A biophysical profile can be coded in a similar fashion as an NST by billing it separately with the single-line approach or the two-line approach mentioned above.

When two BPPs are performed and documented for twins, both should be coded, Witt adds. Using a one-line format, the code 76818 (fetal biophysical profile) would be billed with quantity of two. In a two-line format, 76818 would be listed twice.

Unlike surgical codes, however, radiologic codes generally are not subject to multiple procedure discounting by many payers, so the use of a modifier -51 on the second BPP may not be necessary. As always, it is best to check with your payer on these issues to avoid payment delays.

Watch Out: What Not To Do

Some coders have suggested that a modifier -76 (repeat procedure by the same physician) or modifier -59 (distinct procedure) has worked, but according to Witt this is not the accurate way to code this situation.

While some coders might think that a -76 modifier is correct, further examination of the CPT definition will show that it is used for subsequent procedures and that the modifier was designed for a repeat service on the same patient. In the case of the non-stress test, the patient is a different fetus, and the second NST would not be subsequent to the first NST unless it was repeated on the same fetus.

Modifier -59, says Witt, also is not correct for two reasons. First, the modifier -59 states that the procedure in question is normally an integral part of some larger service performed on the same day. An NST is never part of a global obstetric service, and a second NST would never be considered an integral part of the first NST. Second, this modifier was intended for use with CPT procedure codes that include the phrase separate procedure as part of their descriptor. The code 59025 does not use this terminology.