Ob-Gyn Coding Alert

Ob/gyns order a wide variety of tests for their patients, ranging from Pap collection to urinalysis and cholesterol screenings. Some tests are sent to outside labs for analysis and reporting, others are interpreted "in-house." Knowing which tests or which portions of test fees can be billed by the practice and which tests are billed by the outside laboratory can help circumvent an audit, inappropriate billing or accusations of fraud. Likewise, adherence to CLIA certification rules will keep a practice up-to-date with current regulations.

The most common test ordered in ob/gyn practices is a urinalysis to check for pregnancy. The most frequently administrated urine pregnancy test is 81025 (urine pregnancy test, by visual color comparison methods), yet 84703 (gonadotropin, chorionic [hCG]; qualitative) is also reported often. Results are almost immediate for both of these tests, and there is no need to send the specimen to an outside laboratory. The same is true for tests such as wet mount or KOH slide (87210, smear, primary source with interpretation; wet mount for infectious agents [e.g., saline, India ink, KOH preps]), fecal occult tests (82270, blood, occult, by peroxidase activity [e.g., guaiac]; feces, 1-3 simultaneous determinations) and checking for vaginal pH (82120, amines, vaginal fluid, qualitative).
 
However, many ob/gyn offices lack the proper equipment and staff to conduct tests that are more advanced than those mentioned above. These tests include Pap-smear interpretations, blood panels and quantitative hCG tests for pregnancy. For these tests, specimens drawn in the office are sent to an outside laboratory for evaluation, and the results are returned to the practice, reviewed by the physician and reported to the patient. Therefore, the practice is responsible for one aspect of the test, and the pathology lab is responsible for the other.

Who Does the Work?

When tests are drawn at the ob/gyn office, they are often done in conjunction with an E/M visit or a regularly scheduled well-woman visit. Unless they are a nonroutine addition to a "normal" visit, the taking of the test specimen is frequently not paid by the insurer. In other words, if a Pap smear is widely regarded as a standard portion of a well-woman visit, the practice cannot bill the patient or her insurance company for obtaining the smear.   

But if a patient shows up for her well-woman visit (9939x, periodic preventive medicine ...) and also complains of dizziness and fatigue, the physician may order a series of blood tests. Because drawing blood is not a routine part of well-woman care, the blood draw can be billed with 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). Most blood tests and other workups are often too complex for in-house ob/gyn labs, therefore, these tests are sent to an outside lab.
  
When an outside laboratory evaluates the specimens, it must be paid for that service. Practice coders are often unsure as to which test codes to use for reimbursement, versus which codes the labs use for reimbursement. This can be a billing headache, particularly when the practice has an agreement with the lab to bill for the lab's portion of services. With these types of relationships, the lab does not bill for any tests it has performed. The practice pays the lab for its portion of the test fee and then bills the insurance company the full amount for testing (both for obtaining and analyzing the specimen).
 
Donna Hardwick, accounts manager for M. Silver, D.O., of Nacogdoches, Texas, says her lab prefers to handle its own billing. "Our lab rep tells me we can bill for the 8xxxx codes even though we are the ob/gyn office and not doing the actual study," she says. "We send the blood out to the lab, and they do the study/pathology."
 
If a relationship with outside laboratories like the one described above is working for your practice, you should  keep in mind a few steps when handling their billing. In Hardwick's case, by using the appropriate modifier (see below) her practice can bill for tests it is not qualified or certified to perform in-house. Although it would be impractical to list all the tests performed in ob/gyn offices, these are some of the most common:

General blood test -- 80050 (general health panel)
 

Thyroid test -- 84479 (thyroid hormone [T3 or T4] uptake or thyroid hormone binding ratio [THBR]) 
 

Routine OB testing -- 80055 (obstetric panel)
 

Blood hCG -- 84702 (gonadotropin, chorionic [hCG]; quantitative)
 

Estradiol levels -- 82670 (estradiol)
 

Three-hour glucose tolerance test -- 82951 (glucose; tolerance test [GTT], three specimens [includes glucose]).

If the lab does its own billing, these codes would not be applicable for the practice to bill itself. Coders should keep in mind that when they bill and collect on behalf of a lab, they are essentially providing a free billing service to that lab. "I am quite sure that the labs like these arrangements," says Jan Rasmussen, CPC, president of Professional Coding Solutions in Eau Claire, Wis. "They bill the practice for the tests, and then the practice has to bill the insurance. If the practice doesn't get paid, the lab has lost nothing. Why would an ob/gyn -- or any other physician's office -- want to do their billing for them and work their rejections?"
 
Note that Medicare and Medicaid will not allow for third-party billing, therefore the laboratory must bill these agencies directly.
 
CLIA-Waived Tests

The Clinical Laboratory Improvement Amendments (CLIA) of 1988 regulate lab tests to ensure the safety of lab workers and the accuracy of reporting, among other things. Tests that are routinely done in ob/gyn offices generally fall into the CLIA-waived category, meaning they are so simple that they pose little risk to patients, and there is virtually no room for error when obtaining results. This is the case with urine pregnancy tests and some other common tests. Some of these tests may be what is termed "provider-performed microscopy" procedures, which is a higher level of testing and requires a special CLIA certificate. This category of tests includes semen analysis, KOH and wet mount slides, the fern test, postcoital tests and urinalysis tests that require microscopy, e.g., 81000 and 81001. Any other tests that do not fall into one of these two CLIA categories require varying levels of CLIA certification, depending on the test. Even with waived tests, however, three criteria must be met:

enrollment in the CLIA program
 

payment of biannual fees
 

adherence to manufacturers' test instructions.

When your practice performs a CLIA-waived test, modifier -QW (CLIA-waived test) is appended to many of the CPT codes, signifying all of the above requirements have been met. If your practice is billing nonwaived tests on behalf of an outside laboratory, no additional certification is required, but the CPT test code should be appended with modifier -90 (reference [outside] laboratory) to indicate the testing was not done in-house.

 

Routine tests conducted by the ob/gyn are generally included with the E/M, preventive or global ob visit provided that day. For Pap-smear collection, perhaps the most common test sent to an outside laboratory, practices can attempt to bill 99000 (handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) or Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for Medicare patients. Reimbursement for this code will vary widely from payer to payer. The practice is responsible for demonstrating the medical necessity for all tests ordered by providing an ICD-9 code or descriptor to the laboratory.