Ob-Gyn Coding Alert

If you've ever filed a claim using an "unlisted procedure" code, you know how much effort is involved. To ensure that your ob-gyn gets reimbursed for procedures without specific codes, follow these four pointers:

Tip 1: Describe the Procedure in Plain English

Anytime you file a claim using an unlisted-procedure code (for example, 59899, Unlisted procedure, maternity care and delivery), you should include a separate report that explains, in simple, straightforward language, exactly what the physician did.

Insurers consider claims for unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don't always dictate the most accessible notes. Part of the coder's job when preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman's terms. Be careful to avoid or explain medical jargon and difficult terminology because this has already been provided in the procedure/operative note that you must send with the claims, says Donna C. Kroening, CPC, reimbursement manager for the ob-gyn department at the Medical College of Wisconsin in Milwaukee. You may even want to include diagrams or photographs to better help the insurer understand the procedure.

Tip 2: Compare the Procedure to an Existing Code

An insurer will decide to pay an unlisted-procedure claim by reading your description of the procedure and comparing it to a similar, listed procedure with an established reimbursement value. Rather than leave it up to the insurer to determine which code is the "next closest," you should explicitly make reference to the nearest equivalent listed procedure. After all, the treating physician is best equipped to make this determination. You should also note the specific ways that the unlisted procedure differs from the next-closest listed procedure.

Tip 3: Solicit Outside Advice

If the ob-gyn uses equipment and techniques for which there is no dedicated CPT code, you may be able to enlist the aid of the manufacturer to receive appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies. Use caution when applying manufacturers' suggestions, however, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain payment. Stick to unlisted-procedure codes when no other codes describe the procedure the physician performed and always provide ample documentation to justify the necessity of the claim.

You should also contact your specialty societies, such as the American College of Obstetricians and Gynecologists (ACOG) or the Society for Maternal-Fetal Medicine, to determine if they have any supporting descriptions that may explain the procedure that you can attach to your claim, Kroening says.

Tip 4: Be Prepared in Advance

If you find that the ob-gyn is performing the same type of unlisted procedure over and over, prepare a file of information to have available so you don't have to reinvent the wheel every time you submit a claim, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. Each time a carrier denies a similar claim, you will already have a packet of information ready to send the payer to defend your claim.