Ob-Gyn Coding Alert

Hint: Diabetes before pregnancy is different from gestational diabetes

Did you know that $100 billion of direct and indirect U.S. healthcare costs per year are related to diabetes? With cash like that changing hands, even a few diabetes coding mistakes, especially those related to pregnant patients, can cost your ob-gyn practice big.

The root of the problem: The main issue with a diabetic pregnant patient is that the ob-gyn is essentially taking over the diabetes management and should receive reimbursement for it, experts say. But how are you going to convince your payer that these diabetes treatment services are separate from the global package and require a higher level of management skill?

First, Point Out the Difference

The biggest difference between a diabetic and non-diabetic ob-gyn patient is that the diabetic patient must constantly communicate with her doctor.

Pregnant diabetic patients fall into one of the following categories, each of which requires substantial physician management:

1. Established diabetes type I or II, controlled: Ob-gyns can monitor these patients with more ease than uncontrolled diabetes patients. The reason is because these patients are already familiar with the necessary methods of managing their pre-existing diabetes.

2. Established diabetes type I or II, uncontrolled: Patients who cannot control their pre-existing diabetes through medication and diet will need additional counseling and monitoring. Pregnant women with uncontrolled diabetes tend to have larger babies, thus cesarean sections are more common.

3. Gestational diabetes, controlled or uncontrolled: Gestational diabetes can often go undetected well into the pregnancy. Patients new to diabetes require significant counseling and education to establish a controlling regimen of care throughout the pregnancy.

Build a Case for Extra Office Visits

Extra office visits required for a diabetic ob-gyn patient are common sticking points when you-re seeking reimbursement from carriers.

Why? Ob-gyns see diabetic pregnant patients with much more frequency because of risks to the mother and fetus. Typically, the obstetrician will see the patient every other week for the first seven months, and then even more frequently during the last two months of pregnancy. In some cases, during the last two months of pregnancy, the patient goes to the hospital for a fetal non-stress test (59025-26, Fetal non-stress test; professional component) every other day.

Important: The global ob package does not include an office visit for diabetes management. You should report this as an E/M encounter. For instance, 99212 (Office or other outpatient visit ... established patient, which requires at least two of these three components: problem-focused history; problem-focused examination; straightforward medical decision-making) is generally the standard for the non-global E/M visit. But if the doctor wants to bill for a 99213 (- which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) or 99214 (- which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity), he will need to provide extra medical justification for the higher levels and subsequent visits.

If the patient has other problems, such as uncontrolled diabetes requiring hospitalization or training, then document time spent with the patient and bill for the higher level visit using the time rule, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization based in Salt Lake City.

One strategy: Some ob-gyns working with high-risk patients (and maternal-fetal specialists in particular) have negotiated for high-risk global packages with their payers. They bill for an all-inclusive global and get paid more and are saved the hassles of trying to convince the carrier to pay for the extra E/M visits, Cobuzzi says.

Examine the Extra Testing Problem

You-ve got the extra office visits figured out, but what about additional tests required to manage the pregnancy?

The following tests are often required as part of managing a diabetic ob-gyn patient:

- hemoglobin A1C (82820, Hemoglobin-oxygen affinity [pO2 for 50% hemoglobin saturation with oxygen)

- alpha-fetoprotein (AFP) (82105, Alpha-fetoprotein [AFP]; serum or 82106, ... amniotic fluid)

- ultrasound (76805-76828; [depending on method and approach])

- electronic fetal monitoring (59051, Fetal monitoring) when performed by the non-attending physician. (When performed by the attending physician, you should include this service as part of the global package.)

- amniocentesis (59000, Amniocentesis; diagnostic)

- fetal non-stress test (59025)

- test for spina bifida (such as, 82013, Acetylcholinesterase; 82105or 82106).

The nitty gritty: Your problem in reaping extra reimbursement for these services could stem from your diagnosis coding. You-ll find a code for diabetes with pregnancy in ICD-9's ob-gyn chapter. But even when you report a second code to show the type of diabetes, some payers will not pay for any additional services because you have used a pregnancy code.

Break Down Your ICD-9 Options

Here's how you should report your diabetes diagnosis codes.

Diabetic before pregnancy: For the diabetic ob-gyn patient, you should report the following diagnostic codes:

First, the diagnostic code for the pregnancy is 648.03 (Diabetes mellitus; antepartum condition or complication). This is your primary code.

Second, you-ll need an additional code from the 250.xx code category to identify the type of diabetes. For instance, you should report 250.0x if the diabetes itself was not complicated. You also need a fifth digit for the type of diabetes (insulin versus non-insulin dependent and controlled versus uncontrolled diabetes).

Example: Suppose your physician treats an uncontrolled, type II diabetic suffering from peripheral circulatory disorders. You would report 250.72 (Diabetes with peripheral circulatory disorders; type II or unspecified type, uncontrolled) as the secondary code.

Gestational diabetes: One type of diabetes you won't find within the 250.xx series is gestational diabetes -- a condition that develops only during pregnancy and disappears after delivery. For this type of diabetes, use 648.8x (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; abnormal glucose tolerance; gestational diabetes) and choose the fifth digit (0-4) to indicate when the condition or complication occurred. This will be your primary code. Include V58.67 (Long-term [current] use of insulin) if the physician is treating the gestational diabetes with insulin.

Example: If your ob-gyn saw a 20-week ob patient who was not diabetic before her pregnancy and she is now an insulin-dependent diabetic, you should code her as 648.83 (Abnormal glucose tolerance; antepartum condition or complication), says Amber Kendell, CPC-OBGYN, coder II at Samaritan Health Services in Corvallis, Ore. -After the pregnancy, she might not be insulin-dependent,- says Karen A. O-Malley, office manager for Dr. Michele J. Armenia & Dr. Ann Ressetar in Arlington Heights, Ill.

Examine This Example

So how should you link these diagnosis codes to your CPT codes? Learn from the following scenario.

Example: Your ob-gyn decides to perform an ultrasound on a pregnant gestational diabetes patient. For this service, you would report 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation). You-ll also report 648.83 to reflect the gestational diabetes.