Ob-Gyn Coding Alert

Learn different options to capture the extra work.

When a patient who is carrying twins presents to your ob-gyn practice, you need to be vigilant about capturing the extra work involved with this pregnancy. Your practice may be losing money by using codes for single pregnancies when coding multiple gestation procedures.

The good news is that CPT^® offers a way to correctly code for diagnostic procedures performed on twins. The bad news is that many payers do not recognize the additional work involved with twins. Both challenges can be overcome with correct coding and communication with the payer, explains Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, New Mexico.

The obstetrician or maternal fetal specialist may spend more time supervising a twin pregnancy than a single one, and may need to perform diagnostic tests to monitor the progress of the two babies. Often, the physician is not being reimbursed appropriately because of reimbursement policies or coding mistakes.

For example, CPT^® has a code for a complete ultrasound for multiple gestation (76810, Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)); other services are reported with codes designed for a single pregnancy.

What About NSTs and BPPs?

One reader in Virginia asked if it was wishful thinking to be able to bill for two fetal non-stress tests (NSTs) or two biophysical profiles (BPPs) when there are twins.

Because the code for an NST, 59025, describes only the service performed on a single fetus, when twins are present, two non-stress tests are performed and documented one for each fetus. There are three coding options in this case:

1. Bill Each NST Separately

The most accurate way to bill for NSTs performed on twins is to bill each NST separately, Witt says. This can be done in one of two ways.

The single-line approach would be to indicate a quantity of two for the code 59025 (linked to the diagnosis of why the NST was medically indicated and the presence of twins, O30.0- (Twin pregnancy).

The two-line approach would include listing the code 59025 twice, but the payer may require a modifier 51 (Multiple Procedures) to be added to the second code because of discounting on the second procedure. This would be standard coding for any surgical procedure, as an NST is classified in the CPT^® book.

2. Append Modifier 22

An additional option may be to attach a modifier 22 (Increased procedural services) for unusual and complicated services, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Attaching a cover letter to the claim to explain why additional reimbursement is being requested gives you the opportunity to fully explain the service up front, which will help alleviate denials, Cobuzzi says.

3. Modifier 51 for BPPs May Not Be Necessary

You can code a BPP in a similar fashion as an NST by billing it separately with the single-line approach or the two-line approach mentioned above.

When the ob-gyn performs and documents two BPPs for twins, you should code both, Witt adds. Using a one-line format, the code 76818 (Fetal biophysical profile; with non-stress testing) would be billed with quantity of two.

In a two-line format, you would list 76818 twice.

Unlike surgical codes, however, radiologic codes generally are not subject to multiple procedure discounting by many payers, so the use of a modifier 51 (Multiple procedures) on the second BPP may not be necessary. As always, it is best to check with your payer on these issues to avoid payment delays.

Watch Out: What Not To Do

Some coders have suggested that a modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) or modifier 59 (Distinct procedural service) has worked, but according to Witt, this is not the accurate way to code this situation.

While some coders might think that modifier 76 is correct, further examination of the CPT^® definition will show that it is used for subsequent procedures and that the modifier was designed for a repeat service on the same patient. In the case of the NST, the patient is a different fetus, and the second NST would not be subsequent to the first NST unless it was repeated on the same fetus.