Ob-Gyn Coding Alert

Here’s when you should include the NST in the global period or hospital admission.

Your ob-gyn performs a fetal non-stress test (NST). So you should report 59025, right? Not so fast.

Although ob-gyns can perform NSTs and should be reimbursed for it, you need to know when the ob-gyn is simply using the device to determine if the patient is in labor. That’s when you should include it in the global ob package or the hospital admission code.

Find out if you know how to make this sometimes murky distinction.

Code This When Patient’s Water Breaks With No Contractions

Scenario 1: A patient presents whose water has broken, but she doesn’t feel any contractions. She’s in week 35 of gestation and has dilated 2 cm. Prior to admission, the ob-gyn evaluates the baby with a fetal monitor to be reassured that the baby is OK and the mother is not having contractions. What should you code?

Solution: You should include the labor check as part of the global ob package (for example, 59610, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery), says Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor for a practice in Norman.

Here’s why: In this case, the physician uses the external transducer to determine the mother’s condition and monitor the strength of contractions, Stilley says.. He did not use it to assess the fetus. That’s why the labor check is part of the global ob package.

Lack of Fetal Movement Points to This Code

Scenario 2: A patient at 31 weeks of gestation comes to the doctor’s office complaining that her fetus has not been moving much in the past few weeks. The ob-gyn places the external transducer and performs an NST, using an electronic larynx to stimulate the fetus with noise through the patient’s abdomen when there are no fetal heart rate accelerations with movement during the first 20 minutes of monitoring.

Solution: You would report this service with 59025 (Fetal non-stress test), says Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Oklahoma.

Here’s why: The ob-gyn uses the NST to determine the status of the fetus. The procedure takes longer than a labor check and requires repeated stimulations to assess the specific fetal reaction or lack thereof.

During the procedure, the ob-gyn monitors the fetal heart rate using external transducers. A “reactive” NST will show the fetal heart rate accelerate from the baseline 15 beats per minute for a minimum of 15 seconds at least twice during a 10-minute window. If there are no accelerations after 20 minutes, the ob-gyn may attempt to induce a fetal response with acoustic stimulation through the mother’s abdomen or a vibration that would awaken the baby or cause it to react to the stimulus. This stimulation might be repeated every five minutes for a maximum of two to three times. If there are still no accelerations of the fetal heart rate, then it is interpreted as a “nonreactive” NST.

Difference: NST differs from “routine” monitoring in that the patient is asked to mark fetal movements on the monitor strip (or with newer equipment, fetal movement is detected and marked on the strip), which the physician then interprets as generally reactive, nonreactive, and perhaps “equivocal,” experts say.

Therefore, when the ob-gyn performs an NST to determine fetal well-being, you should report 59025. According to Medicare’s 2017 Physician Fee Schedule, the procedure carries 1.38 relative value units, meaning it’s worth approximately $49.53.

If Transducer Tracks Halting Labor, Code This

Scenario 3: A patient at 32 weeks’ gestation presents in labor. The ob-gyn admits her to the hospital and places the external transducer on the woman’s abdomen, giving her medication to halt the labor. Based on the readings from the transducer, the labor stops.

Solution: Here, you should include the labor check in the hospital admit (99221-99223).

Here’s why: As in the first scenario, the ob-gyn did not use the external transducer to examine the fetus’ condition, but to monitor the patient’s contractions. Therefore, you would not report a separate NST.

Remember, an ob-gyn can perform an NST for a patient in the early stages of labor if a problem with fetal well-being is suspected. But remember that the test must include an indication of fetal movements and the physician must interpret the strip and write (or dictate) a report, which must be entered into the patient record. In other words, it is not enough to put the patient on the monitor and bill for an NST.

The NST is a valuable tool to be reassured that the baby is doing fine. Spontaneous accelerations in response to an active baby are not only reassuring to the physician but often are an education to the mother: “That’s the baby moving? I have felt that before but didn’t know it was the baby moving.”

NST Performed After Admission With No Delivery? Do This

Scenario 4: The ob-gyn admits a patient who is at 40 weeks 5 days. He performs a labor check and requests an NST to be reassured that the fetus is well.

Solution: As long as the patient does not deliver within 24 hours of admittance, the reimbursement for the labor check would be included in the initial hospital care (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...).

Here’s why: Most NSTs are performed when the patient states that she has not felt the baby move very much or the mother is past 40 weeks 0 days, experts say. Because the ob-gyn did not admit the patient for delivery, he can report the initial care separately from the ob global period and the NST. However, he must now report 59025-26 because he is providing only the professional component of the service in this setting.

Post-40 Weeks Scenario May Point to These Codes

Scenario 5: The patient who is 42 weeks presents to the hospital and is not in active labor. The ob-gyn admits the patient and performs an NST to check on the fetus. Then the patient delivers the baby less than 24 hours later.

Solution: You should not report the hospital admission, but some payers may reimburse the NST separately as a diagnostic test (again with the addition of the modifier -26, Professional component).

Here’s why: If the patient delivers less than 24 hours after admittance, you should again consider the labor check part of the ob global care. Consequently, you should not bill it separately.