Ob-Gyn Coding Alert

Key: Was ob-gyn monitoring the pregnancy?

Do you know whether you should include or exclude a visit from the global ob package (59400-59622)? Find out with this seven-part coding challenge.

Decide If Visit is Outside Global Ob

Situation 1: The patient presents for her annual exam. The ob-gyn orders a pregnancy test because he suspects pregnancy. Is this visit inside or outside the global ob package?

Solution: You should count this visit as outside the global ob package. The ob-gyn is not monitoring the pregnancy during this visit.

Your claim should look like this:

• the annual exam (99384-99386 for new patients, or 99394-99396 for established patients) linked to either Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) or Z01.419 (Encounter for gynecological examination [general] [routine] without abnormal findings)
• the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods) linked to Z32.01 (Encounter for pregnancy test, result positive).

Remember: Reporting the routine pregnancy codes Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester), Z34.01 (... first trimester), Z34.02 (... second trimester), Z34.03 (... third trimester), Z34.80 (Encounter for supervision of other normal pregnancy, unspecified trimester), Z34.81 (... first trimester), Z34.82 (... second trimester), or Z34.83 (... third trimester) — or even Z33.1 (Pregnant state, incidental) — is optional. But if you do use one of them, the payer may decide the service should have been included as part of global care.

Home Pregnancy Test? Count This Visit This Way

Situation 2: The patient presents for her annual exam. She tells her ob-gyn that she has taken a home pregnancy test, and it revealed a positive result. Is this visit inside or outside the global ob package?

Solution: You should count this visit as outside the global ob package. Again, the ob-gyn is not monitoring the pregnancy during this visit.

You should report the annual exam (99384-99386 for new patients, or 99394-99396 for established patients) linked to Z01.411 or Z01.419.

Consider This Irregular Periods Visit

Situation 3: The patient presents to your office with a history of irregular periods, and she has had no period for one month. Is this visit inside or outside the global ob package?

Solution: You should count this visit as outside the global ob package. Since the reason for this visit is not to verify whether the patient is pregnant or begin ob care, you should not count this as part of the global ob package.

You should code this as a new or established patient outpatient encounter (99201-99215) linked to a diagnosis for the irregular periods, such as N92.6 (Irregular menstruation, unspecified).

If your ob-gyn orders a pregnancy test during this visit and the result is positive, you should include Z32.01 and link it to the lab test code. If your ob-gyn does not confirm the pregnancy but does test the patient, the correct diagnosis code for the test(s) will be Z32.00 (Encounter for pregnancy test, result unknown).

Tread Carefully For This Scenario

Situation 4: The patient presents to your office with pregnancy complaints and a positive pregnancy test. Is this visit inside or outside the global ob package?

Solution: In this situation, you have to tread carefully. If the patient presents to your ob-gyn simply to “confirm the confirmation,” you can bill this visit outside the global with Z32.01 — as long as the ob-gyn did not initiate any activities that would signal the start of global care such as doing a complete history and exam or starting the flow sheets.

But if the patient or another provider has already confirmed the pregnancy , you should count this as inside the global ob package (59400- 59622). In fact, this is her initial visit and the reason she is presenting for care.

What’s involved: The ob coordination, usually lasting about 30 minutes, includes the ob-gyn reviewing procedure guidelines, including a timetable of when to do lab tests, pelvic exams, amniocenteses, and other ob-related care. Your ob-gyn will also provide vitamins and iron supplements and discuss when to call him. Keep in mind: A nurse or certified nurse midwife can give the patient this information as well. The initial visit included in the global package is not contingent on the physician having seen the patient.

Monitoring the Pregnancy is Key

Situation 5: A new patient transfers into your practice and comes to see your ob-gyn for the first time. She is pregnant and has received care elsewhere. Is this visit inside or outside the global ob package?

Solution: You should count this visit as inside the global ob care.

Rule of thumb: The patient is presenting for obstetric care, and the global code choices for this situation all include an initial new patient visit. You can report an unmodified global code only if your ob-gyn also does the delivery and provides all of the antepartum care. When the patient transfers into your practice from elsewhere, you can either bill the global package code with modifier 52 (Reduced services) if your payer allows, or your payer may ask you to itemize by billing antepartum care (59425 or 59426) and delivery with postpartum care separately (59410, 59515, 59614 or 59622).

Situation 6: A patient presents for the first time with complaints of spotting and a missed period. Is this visit inside or outside the global ob package?

Solution: You should count this visit as outside the global ob package. Again, the ob-gyn is not monitoring the patient’s pregnancy during this visit.

Because you do not know if she is pregnant, you may submit either N92.5 (Other specified irregular menstruation) or N93.8 (Other specified abnormal uterine and vaginal bleeding). But keep in mind that this may not be your only option. If you check the ICD-10 Index, you will note that looking up the term, “menstruation, suppression,” you are directed to code N94.89 (Other specified conditions associated with female genital organs and menstrual cycle). In other words, always check the ICD-10 Index before deciding which code best describes the situation.

You would report one of these codes for the missed period, but you have no clear diagnosis code for the spotting other than these — unless your ob-gyn confirms the patient’s pregnancy during this visit. In that case, the diagnosis code changes to O26.851 (Spotting complicating pregnancy, first trimester), O26.852 (... second trimester), or O26.853 (... third trimester).

Another option might be O20.0 (Threatened abortion) if your physician’s documentation denotes evidence of cervical changes or contractions in addition to the bleeding.

Watch Out For Complications

Situation 7: A pregnant patient presents for her second ob visit complaining of spotting and abdominal pain. Is this visit inside or outside the global ob package?

Solution: You should report this visit as outside the global ob package, but the payer may deny it as inclusive. Under CPT^® guidelines you should code any complaints a pregnant patient has, such as malaise, general fatigue, spotting, nausea, vomiting and pelvic pain. These could be complications of the pregnancy.

Think of it this way: The global ob package is for uncomplicated pregnancy with delivery and uncomplicated postpartum care. You should bill any complications that require extra care separately. However, if the payer disagrees and will not consider payment until the patient has delivered, you will have filed the claim within a possible timely filing period that will permit you to appeal the decision after delivery. Remember, many payers consider the antepartum period to consist of 13 visits, and the reason for the visit after the physician initiates ob care does not affect their decision to include them (unless totally unrelated to the pregnancy).