Ob-Gyn Coding Alert

Make sure you're reporting the correct amniocentesis code for twins.

You may not code for multiple-gestation services every day, but don't let your skills get rusty. If you're not capturing all the associated services, your practice's bottom line could suffer.

Our experts tackle your top-three questions and give you the solutions you need to create the perfect multiple-gestation care and delivery claims every time.

Challenge 1: How To Report the Delivery

Multiple by vagina: If your patient is having twins, most ob-gyns first attempt a vaginal delivery as long as the physician hasn't identified any complications. In this case, you should report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; multiple procedures) for the second, says Rebecca Lopez, CPC, certified coder for Bright Medical Associates in Whittier, Calif.

You might also append modifier 22 (Unusual procedural services) to the global delivery code (59400) if the patient has had more than the average 13 visits and your physician has documented more than routine care. Check with your payer because this may vary with each of them.

Good advice: Send a letter of explanation with the claim to avoid immediate denial by the claim processor. A simple form letter explaining the high-risk nature of multiple-gestation pregnancies will routinely go straight to medical review and save the hassle of denial resubmissions or lost reimbursement through write-offs.

First vaginal, second cesarean: If the physician delivers the first baby vaginally at 36 weeks gestation but the second by cesarean, assuming he provided global care, report 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care) for the second baby and 59409-51 for the first, Lopez says. You should include 651.01 (Twin pregnancy; delivered, with or without mention of antepartum condition) and V27.2 (Twins, both liveborn) as diagnoses, she adds.

For the second twin born by cesarean, use additional ICD-9 codes to explain why the ob-gyn had to perform the c-section -- for example, malpresentation (652.61, Multiple gestation with malpresentation of one fetus or more; delivered, with or without mention of antepartum condition) -- and the outcome (such as V27.2, Twins, both liveborn).

ICD-10: When ICD-9 becomes ICD-10 in 2013, you'll report the following equivalents:

652.61 = O32.9xx2 (for fetus #2, the xx is required because the fetus number must be the seventh digit)

651.01 = To code a twin pregnancy, you have to know the trimester and additional details. Your code choices given that we are stipulating a third trimester pregnancy are: O30.003 (Twin pregnancy, unspecified, third trimester), O30.013 (Twin pregnancy, monoamniotic/monochorionic, third trimester), O30.093 (Other twin pregnancy, third trimester)

V27.2 = Z37.2 (Twins, both liveborn)

Multiple by cesarean delivery: When the doctor delivers all of the babies, whether twins, triplets, etc., by cesarean, you should submit 59510. Don't forget: "You should add modifier 22 to 59510," says Jenny Baker, CPC, professional services coder at the Center for Womens Health in Portland, Oregon, if the physician has documented significant additional work for this delivery. Because the ob-gyn made only one incision, he performed only one cesarean, but the modifier shows that the physician performed a significantly more difficult delivery due to the presence of multiple babies. Be sure to include a letter with the claim that outlines the additional work that the ob-gyn performed to give the carrier a clear picture of why you're asking for additional reimbursement.

Challenge 2: Your MD Did NSTs and BPPs -- What Now?

Ob-gyns commonly use fetal non-stress tests (NSTs, 59025, Fetal non-stress test) and biophysical profiles (BPPs, 76818, Fetal biophysical profile; with non-stress testing; or 76819, ... without non-stress testing) with multiple-gestation pregnancies. You should report 76818 or 76819 for the first fetal BPP, depending on whether the physician also performed the NST. You should "report fetal biophysical profile assessments for the second and any additional fetuses with code 76818 or 76819 with the modifier 59 appended," according to CPT.

NSTs are just like BPPs: Although CPT does not tell you how to bill a multiple-gestation NST, you can extend the BPP coding instruction to use modifier 59 for such NSTs, coding experts say. Alternatively, you could use modifier 22 to indicate the additional work or modifier 51 for multiple procedures. Consequently, you should contact your payer to determine which coding method it prefers.

Challenge 3: What To Do About Amniocentesis

If your ob-gyn performs amniocentesis for a patient carrying twins, triplets, etc., the coding depends on how many needle sticks he performs. If the physician sticks the patient only once to obtain amniotic fluid, you should report 59000 (Amniocentesis; diagnostic) only once. On the other hand, if he draws samples with multiple needle sticks (for example, from each amniotic sac), you should submit additional units of 59000 on separate line items for each stick. You should also append modifier 59 to the second and subsequent amnio codes.