Ob-Gyn Coding Alert

Coding amniocentesis services for twins? Report this code.

Although multiple gestation services will not land on your desk every day, you still have to know what to do when they do. To secure every dollar your practice deserves for these often complicated cases, make sure you’re capturing all the associated services.

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.

Question 1: How Should I 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 Deborah Roorda, CPC, COBGC, certified coder at Rock Hill GynOB in S.C.

You might also append modifier 22 (Increased 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. You should include O30.003 (Twin pregnancy, unspecified…, third trimester), O30.013 (Twin pregnancy, monoamniotic/monochorionic, third trimester), or O30.093 (Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester) and Z37.2 (Twins, both liveborn) as diagnoses supporting the first vaginal delivery and subsequent cesarean delivery.

For the second twin born by cesarean, use additional ICD-10 codes to explain why the ob-gyn had to perform the c-section — for example, malpresentation (O32.9xx2 [for fetus #2, the xx is required because the fetus number must be the seventh digit])  -- and the outcome (such as Z37.2).

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 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.

Question 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.

Question 3: What Should I 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.