Ob-Gyn Coding Alert

Scan your physician's note for these clues when reporting 76811, 76812

Commercials may claim twins are double the fun, but you may not think so when you're trying to code different-day deliveries and ultrasounds. Follow this advice, and you'll have all the answers you need to perfect your multiple gestation claims.

Issue 1: Different-Day Deliveries

Occasionally, multiple-gestation babies will be born on different days. For example, a patient is at 38 weeks gestation and carrying twins in two sacs. One membrane ruptures, and the ob-gyn delivers the baby vaginally. Two days later, the second ruptures, and the second baby delivers vaginally as well.

Solution: You should report the first baby as a delivery only (59409) on that date of service, says Peggy Stilley, CPC, COBGC, ACS-OB, director of auditing services at the American Academy of Professional Coders. For the second, you should bill the global code (59400), assuming the physician provided prenatal care, on that date of service, she adds. "The reason not to bill the global first is that you are still offering prenatal care due to the retained twin," Stilley says.

"I promise that you will have to attach a letter explaining the situation to the insurance company because the appropriate diagnosis for each delivery is 'twins,' even though the ob-gyn has delivered only one," Stilley says. "Your payers will require you to use the outcome codes (V27.2, Twins, both liveborn), but you may have to explain that it is still 'twins' even though only the first [baby] was delivered."

Note: When your diagnosis coding system changes in 2013, V27.2 will become Z37.2 (Twins, both liveborn).

Issue 2: Sorting Out Ultrasound Codes

Invariably, multiple-gestation pregnancies mean multiple ultrasounds. Generally, ob-gyns use obstetric ultrasounds to show viability, the number of fetuses, fetal position, amniotic fluid volume, fetal measurements, placental location, and fetal weight estimation and to allow basic anatomical review. In this case, you must choose the codes based on fetal age:

Example: If the physician orders an ultrasound in gestation week 12 to confirm the presence of triplets, you would report 76801, 76802 and 76802. For each subsequent ultrasound during the patient's pregnancy, you should normally use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus).

"Report 76816 with modifier 59 (Distinct procedural service) for each additional fetus examined in a multiple pregnancy," CPT^® says. For example, with triplets you would use 76816, 76816-59 and 76816-59, Stilley says.

On the other hand, if you perform all the elements associated with a more complex ultrasound code -- such as a detailed fetal anatomic examination in addition to a full fetal and maternal evaluation -- because of high risk or other factors, you should report those codes. In this case, for a multiple gestation you would use 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) for the first fetus and +76812 (... each additional gestation [list separately in addition to code for primary procedure]) for each additional fetus.

Catch this clue: Codes 76811 and 76812 may require more sophisticated equipment and the expertise of a maternal-fetal medicine physician, experts say. Office-level equipment may or may not be able to obtain the necessary detailed imaging, but the majority of payers are only reimbursing these ultrasounds when interpreted by a material fetal specialist and when performed for a specific medical indication. For example, an ob-gyn might evaluate a patient if her pregnancy has an elevated risk of congenital abnormalities of fetal development (birth defects).

Tackle Transvaginal Ultrasounds

Occasionally, the ob-gyn will use a transvaginal ultrasound when he evaluates a multiple-gestation patient.

For transvaginal ultrasounds, you should report 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) only once, according to the American Congress of Obstetricians and Gynecologists (ACOG). You can try adding modifier 22 (Increased procedural services) if the documentation indicates significant additional physician work. But ob-gyns normally don't use the transvaginal scan for an extensive fetal examination.

Heads up: Remember, all obstetrical ultrasounds are transabdominal except 76817, and your physician may have to do a transvaginal in addition to a transabdominal. If the ob-gyn performs both types of ultrasounds during the same visit, you can report both by appending modifier 59 to 76817. But keep in mind, "you must have separate reports for both approaches with corresponding ICD-9 codes that show the medical necessity to perform both approaches," Stilley says.