Ob-Gyn Coding Alert

According to coding experts, one of the most frequently asked questions about ob-gyn coding is routine global obstetric billing. The concept is simple: rather than breaking apart charges for each service and procedure involved in a pregnancy, antepartum care, labor and delivery and postpartum care are bundled together into one charge. The question comes in knowing what exactly is and is not included in the global codes.

Whats Included/Excluded in the OB Global?

In the CPT, under the section for Maternity Care and Delivery (59000-59899), there are four global codes for routine obstetric care, including antepartum, delivery and postpartum. The codes were designed to cover the differing work levels involved in four possible common obstetric scenarios:

59400 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care.

59510 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care.

59610 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care after previous cesarean delivery.

59618 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery.

According to Lydia Dollar, senior coding and reimbursement analyst and physician compliance officer at Bay State Medical Education and Research Foundation in Springfield, MA, while global codes are straightforward and most carriers and state Medicaid providers recognize them. However, the difficult part comes in knowing which procedures and services will be eligible for reimbursement. The best place to start is to first know what the CPT guidelines include and exclude in their ob global codes:

Included:

The initial patient history and examination, including recording of weight, vital signs and any counseling or advice provided about the pregnancy during the initial visit.

Monthly visits up to 28 weeks gestation to monitor ongoing progress, including examination, weight and vital sign monitoring, assessment of fetal heart tones, routine chemical urinalysis

Bi-weekly visits for examination and monitoring of pregnancy from 28 to 36 weeks gestation

Weekly visits for examination and monitoring of pregnancy from 36 weeks to delivery

Admission to the hospital for labor and delivery including admission history and physical examination

Management of uncomplicated labor

Routine fetal monitoring during labor

Ordering and administration by the attending
physician of medications during labor (e.g. Pitocin, pain control)

Artificial membrane rupture prior to delivery

Vaginal delivery including episiotomy, forceps, minor laceration repair and placenta delivery

Cesarean delivery including all the necessary routine surgical procedures

Postpartum care including hospital and office visits and any routine care following a vaginal or cesarean delivery

Excluded:

Charges for the initial testing for a unconfirmed pregnancy

Ultrasound testing

Fetal biophysical profile

Fetal echocardiography

Amniocentesis

Cordocentesis

Fetal non-stress test

Observation care for premature labor prior to 36 weeks gestation (hospital visits within 24 hours of delivery are considered part of the global package)

Services for problems incidental to pregnancy such as toxemia, hypertension, maternal diabetes etc.

Note: Once again, each carrier may vary with what it includes or excludes from the global codes, the above bulleted items are according to the CPT.

Guidelines for Using Global Codes Correctly

A few health plans (including Medicaid carriers) that do not accept these global codes. But for the majority that do, the following guidelines will help.

1. Timing is everything. The time to bill for these codes, according to Liza Green, RRA, CCS-P, revenue coordinator for Ob/Gyn for the Mayo Clinic of Scottsdale, AZ, is after the delivery. We dont usually submit a bill until we have a complete picture of everything that went on during the pregnancy, she explains. Even when there have been extra charges or complications, Green says she waits at least until the delivery. Then she is able to look at all the charges and procedures and determine the best way to code the obstetric care. The exception may be when you have a severely complicated pregnancy with other medical problems in which you are providing significant additional services and procedures prior to delivery. In this case, you may want to go ahead and submit a bill for the services incidental to the pregnancy before delivery.

Tip: Make sure that when a delivery is complete, you have a system whereby someone on the billing staff looks back over the patients chart to make sure that you are coding for everything done during the entire period. In an effort to get the global bill submitted, other services may be overlooked.

2. Additional services during pregnancy. Because the global codes only cover whats considered routine, other charges can be reported separately and in addition to them. And remember, additional charges dont automatically throw you out of the global. For example, if an ultrasound is performed (as is the case in most pregnancies now), you would simply bill separately for the appropriate 76805-76816 code attached to the diagnosis code V28.4 (Screening for Fetal Growth Retardation using Ultrasonics).

3. Medical Problems Complicating Pregnancy. When the ob patient has medical problems such as toxemia, hypertension, hyperemesis, or premature rupture of membranes that place the patient at a higher risk and require more visits and services, again, you can still use the global codes but add on these additional charges. It is generally accepted that the global package includes 10-15 total antepartum office visits (with an average of 13 under the CPT definition). If the medical problems do not require extensive additional work and can be managed while the patient is in for her prenatal visits, such services will probably be considered part of the patient's routine prenatal care. If the problems require the patient be seen more frequently, code the additional visits using the appropriate Medicine or Evaluation and Management codes linked to the appropriate diagnosis codes. Remember, reimbursement depends on your ability to prove medical necessity, so be sure you have the appropriate diagnosis codes and documentation to justify the extra services over and above those included in the global package definition.

4. Labor, Delivery and Surgical Complications. Code separately for additional services provided during the delivery, such as an extensive repair of a laceration. The same applies for surgical complications. Occasionally, during a cesarean delivery, other services are provided such as an appendectomy, hernia repair, tubal ligation or removal of a cyst. Again, these should be coded separately, and may need to be supported with an operative report or letter of explanation, but they do not take you out of the global codes.

5. Providing Partial Services. You will not use the global codes when youve not provided global services. But there are some exceptions to this rule. For example, if you first see a patient late in her pregnancy and only provide five antepartum care visits, and then perform a vaginal delivery and postpartum care, and you are the only one who has provided her with any prenatal care, you can use the global codes, but should add a modifier -52 for reduced services. If on the other hand, she transfers into you practice so that another physician is also billing for antepartum care, you would code the antepartum services and delivery/postpartum services separately by the number of total visits she was seen prior to delivery. In the above example, use code 59425 for the antepartum visits and 59410 for the delivery and postpartum care. If you see a patient for 1-3 antepartum visits, you should simply use the appropriate Evaluation and Management codes.

6. Know your Carriers. With a firm handle on what the CPT codes include and exclude, you need to know what your carrier includes. According to Dollar, carriers will often try to include or exclude various services in the global codes, so find out what their definition of global is. This does not mean that you should code specifically for each carrier, but it will give you a good idea of what to expect for reimbursement and a basis for explaining to your patients why certain services may not be covered by their carriers, and why they personally will be responsible for payment.

When Do Global OB Services Begin? The question of when ob global begins relates to how and when pregnancy is established. In a random survey of practices, we found that most physicians require a reliable pregnancy test prior to setting up the initial ob visit (usually an in-depth visit of about 40 minutes), which signals the beginning of the ob global. Practices are mixed in what they consider a reliable test. Many do not accept home pregnancy tests and want a test from a primary care physician or some other reliable source. In addition, with some ob/gyns serving as primary care physicians, they may be seeing patients who suspect pregnancy. Therefore, if the patient does not have an established pregnancy test (from another physician or clinic), many practices are triaging the initial call from the woman and offering an inexpensive pregnancy test to establish pregnancy (without seeing a physician). If the patient is requesting to be seen for problems that may suggest pregnancy but pregnancy has not been established, then a short office visit is scheduled along with the pregnancy test and coded with the appropriate Evaluation and Management codes. However, ACOG believes that the first ob visit is when the patient comes in knowing she is pregnant (even with a home pregnancy test) and the ob record is established at that visit. If the pregnancy is not confirmed at that time then the visit becomes a gyn appointment using the ICD-9-CM code for ammenorrhea. (626.0).