Ob-Gyn Coding Alert

The global service also includes routine follow-up care, according to ACOG guidelines. This follow-up includes checking an incision during a post-op visit and cleaning and redressing the surgical wound.

But coders risk losing out on reimbursement if they assume that the global service also includes other, more complicated care that sometimes must happen after cesarean surgery. Procedures not included in the postpartum services for 59510 are:

Postoperative complications following a cesarean section can range from minor wound infections and breast infections to disrupted sutures, highly septic wounds and internal bleeding. ACOG considers treatment for any of these conditions separate from routine global post-op care. Individual carriers, however, do not always reimburse based on ACOG's guidelines, and you may have to appeal to receive proper payment, warns Peggy Stilley, CPC, office manager for Women's Heathcare Specialists, an Oklahoma University-based private ob/gyn practice in Tulsa. "We appeal based on how regularly we perform the procedure and the amount of potential reimbursement that is involved. But carriers' internal policies shouldn't stop you from billing accurately," she maintains. The nature of the complication determines how you should bill and code it.

Minor infection Suppose you are coding a wound or breast infection that the physician was able to treat in the office. Pair the appropriate diagnosis code with the E/M service code for the treatment of the infection, Witt says. For a cesarean wound infection, the ICD-9 code is 674.34 (Other complications of obstetrical surgical wounds, infection, postpartum condition or complication). For a breast infection, the appropriate diagnosis code is 675.04 (Infections of nipple, postpartum condition or complication).

The E/M service may involve the physician examining the patient, discussing treatment options and perhaps writing a prescription for antibiotics. You can bill an established patient E/M code (9921x, Office or other outpatient visit for the evaluation and management of an established patient ...), and the level will depend on what the physician has documented in the chart. "There is no CPT modifier that describes a post-op complication that is directly related to the surgery other than those requiring a return to the operating room," Witt stresses. So when you submit the claim for the additional E/M service, you should include a detailed note from the physician explaining the nature of the problem and its treatment, Witt says.

Major infection or disruption A widespread wound infection or stitches that pull and result in internal bleeding are serious complications that require an almost immediate return to the operating room. This far-from-routine post-op care is separately billable.

In such cases, you should link the infection (674.34) or the disruption of cesarean wound (674.14) and hemorrhaging (also 674.34) to the appropriate procedure codes. For cleaning and draining the infected wound, you should report 10180 (Incision and drainage, complex, postoperative wound infection). For the disruption and bleeding, 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated) applies. If the physician performs either of these services in the hospital operating room (OR), you should append modifier -78 (Return to the operating room for a related procedure during the postoperative period).

Unrelated service Suppose a postpartum cesarean patient reports with a complaint like strep throat. If the complaint has nothing to do with the pregnancy, you can always bill for the services, even within the six-week global postpartum period. Report the appropriate E/M code for an established patient and append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period).

For unrelated surgical services that take place during the hospital stay, such as a tubal ligation (58605, Ligation or transection of fallopian tube[s], abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization [separate procedure]), you should report the CPT code appended with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period). Many carriers require a different diagnosis code to show medical necessity for the unrelated surgical procedure, Stilley says.

For services unrelated to the original surgery that require a return to the OR within the six-week global period following delivery, you should also append modifier -79 to the procedure code.

An example of this unusual scenario is a myomectomy (58140, Myomectomy, excision of leiomyomata of uterus, single or multiple [separate procedure]; abdominal approach) for the removal of a growth that is unrelated to the pregnancy and c-section.

The above billing guidelines will hold true for most commercial payers, but federal payers like Medicaid and CHAMPUS/Tricare have different ideas about what the global postsurgical period includes. Under CMS rules, the only complications during the post-op period that are paid are those requiring a return to the OR, not treatment in the office.

The CHAMPUS/Tricare military health program allows payment for a return to the OR but will not reimburse additionally for medical complications until the patient has been seen twice on an outpatient basis following the cesarean section (see http://www.tricare.osd.mil).