Ob-Gyn Coding Alert

In order to augment their services and improve efficiency, many ob/gyn practices are increasing their use of certified nurse midwives (CNMs) and nurse practitioners (NPs). The American College of Nurse-Midwives confirms this trend by reporting a 300 percent growth in the number of CNMs in the last decade. In eight years, the number of annual deliveries performed by CNMs has more than doubled. No wonder ob/gyn practices are increasingly concerned about coding for these providers. In fact, Karen S. Fennell, RN, MS, senior policy analyst for the American College of Nurse-Midwives, says, One of the most commonly asked questions by CNMs is, Which prenatal codes do I bill under?

1. Coding For A Mid-Level Provider

The trick to coding for mid-levels has nothing to do with the fact that the provider is not a physician, says Trudy A. Brody, billing office supervisor for an ob/gyn practice with five mid-level providers in Medford, OR. You use the exact same codes as you would use for the physician. The difference comes in how the claim is reimbursed, and reimbursement depends on how the service by the CNM or NP is provided. If the service is incident to the physicians professional services, then reimbursement should be at the same level as the physician. On the other hand, if the CNM or NP is providing a professional service independent of the physician, then reimbursement is lowertypically only 65 to 85 percent of what the physician might collect for the same service.

Note: The Balanced Budget Amendment of 1997 increased Medicare reimbursement for physician assistants and NPs to 85 percent of the physician fee schedule and allowed them to bill under their own provider identification numbers. However, carriers were given until July 1, 1998 to implement the new policy. Check with your local Medicare carrier about submitting claims.

2. Incident To Services and Medicare Rules

With incident to services getting reimbursed at 100 percent of physician rates, the logical question to ask is why not code all services that way? The good news is that NPs and CNMs who work for ob/gyn practices are providing their services incident to the physician most of the time. Incident to means that the mid-level provider is acting on behalf of the physician. It is as if the ob/gyn herself performed the service and, therefore, the practice is reimbursed as such.

But, when billing Medicare, a coder cannot assume that the mid-level provider is performing services incident to the physician. Both the mid-level and the physician must meet certain qualifications set by Medicare in order to be eligible.

In fact, according to Neil B. Caesar, JD, president of The Health Law Center in Greenville, SC, practices using mid-levels can be exposed to substantial legal risk if they bill incorrectly. For services to be correctly billed incident to, they must meet the following criteria:

1. Mid-level providers must be qualified, which means they must have the appropriate state licenses and have met the all professional certification requirements as specifically outlined in the Medicare rules.

2. Mid-levels must be employees or leased employees of the physician, and, most importantly, the physician must directly supervise them.

3. To supervise, the physician need not be present in the same room, but he or she must at least be in the office suite and accessible to assist or advise the mid-level provider while care is being rendered, says Caesar.

If all of these qualifications are met, then, and only then, can the bill be coded incident to and use the physicians name and provider number at the bottom of the billing form.

Tip: Remember, the CPT codes are the same, regardless of who performs the service. The distinction is whose name appears on the billing form.

Note that Medicare does permit a few exceptions to these rules. For example, a mid-level can visit a patient at home if that patient qualifies as homebound by Medicares definition. In addition, if the patient is in one of the rural areas designated as a rural Health Professional Shortage Area (HPSA), then the supervising physician need only be accessible by phone.

3. Incident To and Other Payers

Most of the time, other insurance carriers follow Medicares lead, but in the case of mid-levels, the rules governing incident to services are usually more lenient. Mid-levels are generally allowed to practice more independently and with less supervision. Many payers will reimburse mid-level incident to services at the same rate as the physicians, although coders and practices managers told us that some payers are reimbursing less when they know that service was delivered by a mid-level. Coders are advised to check their insurance contracts and state laws for regulations that affect them. Based on the findings, practices may be able to appeal some claims that were paid at a lower rate.

4. Mid-level Professional Services

Many NPs and CNMs working within ob/gyn practices see their own patients and bill their own services. If this is the case in your practice, then you must code the service using the credentialed mid-level providers name and identification number at the bottom of the billing form (if permitted in your state). This notation means that the NP or CNM provided the service without the direct supervision of the ob/gyn. You will use the same codes as you would with the physician, and bill the same amounts, however, you may be reimbursed less.

Remember, Brody says, to make sure all mid-levels are credentialed with each payer. This process requires a detailed application and making sure the mid-level has the proper provider identification number.

5. Mid-Levels and Global Ob Billing

An interesting situation arises in practices using CNMs when both the CNM and the physician see the patient during the global ob period. Whose name should appear on the global bill, and was the global service incident to? According to Brody, it could go several ways, but, generally, whoever performs the delivery is whose name appears on the billing form. However, if the CNM performs the delivery and the physician is present or in the same suite, the global service should be billed under the physicians name.