Ob-Gyn Coding Alert

Perinatologists or maternal fetal medicine (MFM) specialists often are called in on a one-time-only basis for consultation with a high-risk ob, or when the patients primary ob/gyn has suspicions or concerns of a complication in the pregnancy. The perinatologist typically may perform a level-four consultation with the patient (99244, office consultation for a new or established patient, requiring a comprehensive history, comprehensive examination, and medical decision-making of moderate complexity) and frequently runs additional tests. Yet getting paid for those visits as consultations remains a challenge for many of these specialists.

Problems Convincing the Carrier

Cheryl Christy, billing coordinator at University Perinatal Consultants, works with seven perinatology professors and assistant professors at Ohio State University in Columbus. The physicians also have a private practice and provide high-risk coverage for every hospital in Columbus. Christy typically has several doctors at different hospitals every day, where they all cover labor and delivery.

When asked about problems with reimbursement, Christy recounts difficulties, including a recent newsletter article from an insurance company. An article in a provider newsletter from one of our major carriers said they would automatically deny every consult submitted and downcode it to an evaluation and management (E/M) service for a new patient. The article explained that because the providers were billing so many consultations incorrectly, they were going to downcode across the board. The same article said that even if we submitted a hard copy of the referral and attached documentation of the work that was done and the letter from our doctor back to the PCP (primary care physician) all steps that would prove a consultation the consult would be denied. We would have to go through the appeals process to get paid for the work we did, she adds.

Other carriers also only pay for a regular E/M visit, which reimburses at a lower rate than a consultation. Even when weve gotten the consult precertified, the claim gets denied, Christy says. Part of the denial problem may be the insurance companies computer software programs. Christy explains that the software does not read the box on the HCFA 1500 form that lists the referring physician. Therefore, the computer reads the visit as a regular E/M for a new patient, rather than as a consultation. In the best-case scenario, a phone call to the carrier gets the reimbursement ball rolling, but often there is a lengthy appeals process for denied claims.

Doris Queen, RN, clinical nurse for Oscar Mims, MD, FACOG, a solo-practice perinatologist in Washington, D.C., handles billing and coding as well. She shares the frustrations with getting paid for consultations. Insurance companies are not interested in hearing that Dr. Mims is a perinatologist, says Queen. They focus on the idea of global care and can only grasp the concept of one ob seeing the patient throughout the entire pregnancy. Queen agrees that the problem lies not only in managed cares reluctance to accept perinatology, but in the computer systems as well. Once the computers read a new PIN (physician identification number) on the HCFA 1500, form, they just see transfer of care and dont read the visit as a consultation.

Queen is frustrated especially because she and Mims attended a coding class that essentially told them they were doing their billing and coding the correct way. But perinatology is still a gray area, says Queen, because although the specialty uses diagnostic codes identifying high-risk obstetric conditions and complications, the choice of procedure or E/M codes is not specific to perinatology. Without such codes, our claims are going to keep falling through the cracks.

Tests Get Bundled

Problems dont stop with the consultations being denied. Christy reports that procedures conducted by the physicians routinely get denied with a number of different carriers. A referring physician sends us the patient because he or she has concerns about the health of the fetus, so there are several steps we take to assess fetal well-being, she says. A typical office visit in which the patient has been referred employs the following codes:

99244 (office consultation for a new or established patient)

76805 (echography, pregnant uterus, B-scan and/or real time with image documentation; complete [complete fetal and maternal evaluation])

If, at the same time, the physician recommends or the patient asks for an amniocentesis, the following codes apply:

59000 (amniocentesis, any method)

76946 (ultrasonic guidance for amniocentesis, radiological supervision and interpretation)

82106 (alpha-fetoprotein; amniotic fluid) for the tests run on the amniotic samples.

The ultrasonic guidance runs afoul of many insurers. Practices are getting denials and are accused of unbundling the codes. But Christy feels this is a case of the insurance companies computers not being up to date. Until 1992, the amnio and the ultrasonic guidance were considered one procedure and coded as 76947. But then the code was split into two procedures, making it possible for the amnio and the ultrasound to be billed separately, she says. Yet according to Christy, many of the carriers have not updated the codes in their computers, so the claim is still being rejected as it is read as one procedure rather than two.

Another part of Christys particular problem may be that her practice is doing the complete ultrasound (76805) at the same session as the ultrasonic guidance (76946). The carrier may be rejecting the claims as redundant. But as Christy explains, this is a question of the order in which the procedures are done. The patients are sent to us for the 76805, which takes an in-depth study of the fetal and maternal organs. After the 76805, the patient and doctor decide whether an amniocentesis is desired or necessary. Although it might be easier from a billing standpoint to have the patient come back for a follow-up in which the amniocentesis with the ultrasonic guidance is performed, it just is not practical for many patients. We see a lot of women from Kentucky, West Virginia and other parts of Ohio because there are no perinatologists in many of these rural areas. We do the procedures on the same day at the patients request because many of them cannot afford to take another day off work to come back for more tests. We always try to notify the carrier within 24 hours that we have done both these tests.

Making the System Work

Peggy Stilley, CPC, office manager for OB-Gyn PPP, a university-based private ob/gyn practice with specialists in MFM, infertility and urogynecology, in Tulsa, Okla., was shocked to hear of other perinatologists payment problems. Realistically, consulting is the majority of a perinatologists practice. We have had no problem being reimbursed for consults, nor have we seen a pattern of denial, even from our Medicaid payers or any of the private insurers, she says.

Stilley explains that there are several steps her practice takes to ensure accurate payment. At the outset, when making appointments from referring physicians, she always asks for authorizations for a consult, ultrasound and possible amniocentesis. Also, we make sure we have all the appropriate documentation required for a consult: the request from a physician for an opinion, documentation of face-to-face time, any testing or additional services performed, and a written report to the referring physician, she adds. For good measure, billing managers should make a copy of the carriers rules on consultations and submit that along with their claim.

The answer may lie in learning to finesse a system that seems predisposed to claims denials. For many perinatologists, this often means taking significant discounts. But reimbursement staff who establish a phone relationship with the carrier have some advantage. By getting the claims adjuster to understand that your perinatologist is a consultant and not a PCP, the reimbursement message might just get through. Likewise with ultrasounds and other tests, even if it means going over the adjusters head, make every effort to make it clear to the carrier why each of these procedures is necessary.

Help Is Out There

Even with measures to try to correct as many reimbursement problems as well in advance as possible, many specialists still have a struggle on their hands for consultations. Fortunately, some help is out there. In addition to submitting proper documentation, perinatologists can look to ACOG (American College of Obstetricians and Gynecologists) for assistance. ACOG has addressed the multiple-ultrasound issue in a formal letter that can be sent to the payer with the claim. A copy of this letter can be obtained by contacting ACOG via e-mail at coding@acog.org.

Failing those measures, doctors should use every resource available to appeal the claim denial. This includes sending copies of all appeals documents to the state insurance commissioner, the patient and your local legislator. Carriers that reject legitimate consultation claims across the board when such care is covered under the patients healthcare contract are not abiding by well-established and accepted rules for coverage and reimbursement, and there are outlets and resources to stop this practice.