Ob-Gyn Coding Alert

To get reimbursed appropriately for the new drug Mifeprex, ob/gyn coders need to know the details of each stage of the three required visits, as well as the importance of thoroughly documenting the face-to-face time with the patient.

In late September of last year, the Food and Drug Administration (FDA) approved Mifeprex for use in non-surgical abortions in the United States. (See Special Report on RU486 Coding, an insert in the October 2000 Ob-Gyn Coding Alert.) Since then, physicians, insurance companies and politicians have adjusted and responded to this product, which changes the landscape of legal abortion in the United States. Our original article on Mifeprex coding outlined the three stages of administering the drug and how to code for them. The patients first visit, assuming she has decided to terminate the pregnancy, involves extensive physician counseling on the use of the drug. At the initial visit, many physicians will conduct an ultrasound (although not required by law) to most effectively date the pregnancy (to make sure the pregnancy is less than 7 weeks old). Upon complete evaluation, the Mifeprex is administered orally and the patient goes home. Visit one is coded:

99204 or 99214 office or other outpatient visit for the evaluation and management of a (new or established) patient ...;

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

76815 echography, pregnant uterus, B-scan and/or real time with image documentation; limited (fetal size, heart beat, placental location, fetal position, or emergency in the delivery room); and

J8499 prescription drug, oral, nonchemotherapeutic, not otherwise specified, or 99070 supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).

The second visit occurs two days later, and the patient is given two tablets of Misoprostol, the companion drug to Mifeprex necessary to complete the non-surgical abortion. This visit is coded for both an evaluation and management (E/M) service and the drug supply:

99213 or 99214 office or other outpatient visit for the evaluation and management of an established patient ...; and

J8499 prescription drug, oral, nonchemotherapeutic, not otherwise specified; or

99070 supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).

The third and final visit takes place 12 days after the second visit, to determine that the non-surgical abortion is complete and there are no complications. Assuming there are no complications, an E/M service is the only billable aspect of the encounter and is coded:

99213 or 99214 office or other outpatient visit for the evaluation and management of an established patient.

Coding and Documentation Alternatives

Upon reading our initial story on Mifeprex, Bruce Ferguson, MD, an Albuquerque, N.M., family practitioner specializing in womens health, offered some additional input on coding. When choosing the E/M code for the time spent counseling the patient (at the initial visit), says Ferguson, it is especially important to emphasize the time factor. Although the medical decision-making will be of moderate complexity at the first visit, the history and exam will seldom be more than problem-focused so this would not meet the criteria of a level-four visit (99204 or 99214).

But to support a level-four service, particularly for a new patient visit (99204), the face-to-face counseling between physician and patient would have to be at least 45 minutes. Although Ferguson does not dispute that a level- four visit is typical for the initial Mifeprex counseling, he feels that thorough documentation of face-to-face time with the patient is crucial, particularly since the other elements of history and exam might not support the level-four visit.

Ferguson also points out that the companion drug, Misoprostol, can be given orally or vaginally. If given vaginally, the physician would code 59200 (insertion of cervical dilator [e.g., laminaria, prostaglandin] [separate procedure]) because the Misoprostol is a prostaglandin product.

Ferguson says that while patient interest in Mifeprex is high, that interest is tempered by information regarding the cost. A supply for one patient (three tablets) is sold to physicians for $270. The final cost to the patient for the non-surgical abortion will depend on local conditions and physician discretion, as do fees for surgical abortion.

The Reimbursement Picture

Since the FDAs decision in September, many providers have been waiting for the dust to clear in terms of reimbursement for Mifeprex. Representatives from Danco Laboratories, the maker of Mifeprex, are working with the insurance community to develop reimbursement policies. According to Heather ONeill, director of public affairs for Danco, the company is working with payers as to their intentions with reimbursement. ONeill says that initially, payers who intend to reimburse for Mifeprex will do so by accepting the same or similar coding sequence to that printed above. Most payers to whom weve spoken are talking about reimbursing for Mifeprex using the E/M and drug supply codes, she says. Danco also plans to initiate discussions with the AMA to establish a CPT code for Mifeprex to simplify the reimbursement process. That global code would presumably include the three E/M visits, drug supplies, and may or may not include an ultrasound to date the pregnancy. Regardless of whether a CPT code is developed, Mifeprex is still a less costly option to the payer than a surgical abortion, ONeill says. This is because a surgical abortion has built-in costs for both the professional services and the facility fee, and Mifeprex involves only professional fees.

According to ONeill, the trend seems to be that payers that already reimburse for surgical abortions are planning to reimburse for Mifeprex abortions. Those that do not now pay for surgical abortions will not pay for Mifeprex abortions. The insurance companies have already made their policy decisions, ONeill says. So at this point, Mifeprex is more of an operational issue for those payers planning to cover it.

Ferguson adds that so far, no carrier in his region has given practitioners any definite codes to use for Mifeprex. One carrier, Ferguson adds, has said they are developing a global fee for Mifeprex abortion, to include all office visits, ultrasounds, medications and counseling, but havent got it all figured out yet. And in an even longer process, New Mexico Medicaid has reported that it plans to pay for Mifeprex abortions, but that current Medicaid regulations dont allow reimbursement to physician offices or clinics for oral medications. Therefore, state regulations will need to be changed, and the agency doesnt know how long that will take. In New York and New Jersey, Medicaid has already stated that it plans to cover Mifeprex.

Legislative Activity

New Mexico Medicaids efforts to change regulations and allow for reimbursement of Mifeprex abortion may well get mired in a legal battle after the first of the year. When the state legislature convenes in February, it is reasonable to expect that opponents of abortion and/or Mifeprex-induced abortion will attempt to block access to the drug. Because state Medicaid and Medicare money is approved by the state legislature, any changes to state Medicaid policy would have to meet with legislative approval as well, which might not come easily given the divisiveness of the abortion issue.

On a national level, immediately after the FDAs approval of Mifeprex, legislation was introduced that would place criteria additional to that set by the FDA as to who could administer Mifeprex and how. The senate bill is now in the hands of the Committee on Health, Education, Labor and Pensions, where action is expected some time this year. Opponents of the legislation argue that the bill, if passed into law, not only has the potential to restrict womens access to Mifeprex abortion but also could impede medical investigations into other beneficial uses of Mifeprex. Studies suggest that the drug may be beneficial in labor induction and in treating a number of reproductive problems, such as infertility and endometriosis and certain breast cancer tumors. It may assist in treating AIDS.