Ob-Gyn Coding Alert

Tip: Make sure you include labor checks in the global ob code.

Do you want to code fetal non-stress test (NST) using 59025? Better make sure the equipment or the mother records the fetal movement. Otherwise, count the fetal monitoring as routine.

Find Out What Makes a True NST

When you report 59025 (Fetal non-stress test) for NST procedures, make sure you're reporting them in the appropriate situations.

What happens: During the NST procedure, the ob-gyn evaluates the patient and assesses fetal well-being without using IV medications, says Denell Engstrom, CPC, coding manager and billing specialist at the Woman's Clinic in Boise, Idaho. Overall, the test lasts 30-40 minutes, during which the ob-gyn monitors the fetal heart rate, fetal movement, and contractions (if present) 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. The acoustic stimulation or vibration is for waking the baby or to cause it to react to the stimulus. The ob-gyn might repeat this stimulation every five minutes for a maximum of two to three times. If the baby's heart rate still does not accelerate, the ob-gyn will determine this to be a "nonreactive" NST.

Key concept: The most important factor is that the equipment is marking the fetal movements on the strip. Older equipment or very faint movements will require that the patient push a button when she feels fetal movements. The ob-gyn interprets the strip and writes (or dictates) a report that he must include in the patient's record.

For example, your ob-gyn sees a patient at 31 weeks gestation who complains that her fetus has not been moving much in the past few weeks. During the first 20 minutes of monitoring, the ob-gyn uses the external transducers and detects no fetal heart rate accelerations. Afterward, he tries an electronic larynx to stimulate the fetus with noise through the patient's abdomen. The mother marks the strip when she feels movement throughout the 30-40 minutes of the test.

You would report this service with 59025 because the ob-gyn is using the NST to determine fetal status. Notice how this procedure takes longer than a labor check and requires repeated stimulations to assess the specific fetal reaction or lack thereof.

Heads up: If the ob-gyn performs this test in the hospital setting, you should add modifier 26 (Professional component) to 59025. You should add modifier 26 to 59025 because the hospital owns the equipment and will report for that portion of the service.

Don't Overlook ICD-9

When you're reporting 59025, you'd better be sure you've got supporting documentation--and the supporting diagnosis to justify this code. "You should make sure you have a specific diagnosis and not just a pregnancy code (V22.x). Most payers do not cover the NST unless your ob-gyn documented a specific reason," Engstrom says.

Example: You might use the decreased fetal movement code (655.73) because the ob-gyn is monitoring the baby.

ICD-10: When your diagnosis coding system changes in 2013, you'll have several equivalents to 655.73. This is one of the codes that requires you to identify the fetus that has the problem so do not forget the 7th character. They are:

• O36.8120 -- Decreased fetal movements, second trimester, not applicable or unspecified
• O36.8121 -- ... fetus 1
• O36.8122 -- ... fetus 2
• O36.8123 -- ... fetus 3
• O36.8124 -- ... fetus 4
• O36.8125 -- ... fetus 5
• O36.8129 -- ... other fetus
• O36.8130 -- Decreased fetal movements, third trimester, not applicable or unspecified
• O36.8131 -- ... fetus 1
• O36.8132 -- ... fetus 2
• O36.8133 -- ... fetus 3
• O36.8134 -- ... fetus 4
• O36.8135 -- ... fetus 5
• O36.8139 -- ... other fetus
• O36.8190 -- Decreased fetal movements, unspecified trimester, not applicable or unspecified
• O36.8191 -- ... fetus 1
• O36.8192 -- ... fetus 2
• O36.8193 -- ... fetus 3
• O36.8194 -- ... fetus 4
• O36.8195 -- ... fetus 5
• O36.8199 -- ... other fetus.

Warning: Don't Use 59025 for Labor Checks

Ob-gyns often use a fetal monitor to determine if a woman is in labor, but that doesn't mean you should report 59025. Most likely you'll include this fetal monitor use as part of labor management or the global ob package (such as 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care).

Example: A patient at 38 weeks gestation presents to the ob-gyn saying her water has broken but she doesn't feel any contractions. The ob-gyn checks her and sees that she's dilated 3 cm. Before admitting her to the hospital, the ob-gyn evaluates the situation by placing an external transducer to determine if the mother is experiencing contractions. Because the ob-gyn uses the fetal monitor to assess the mother and not fetal well-being, you should include this test as part of the labor check, which would be part of the global ob package (such as 59400).

Best bet: "When a patient comes in and is hooked up to the monitor, and the ob-gyn determines the patient is in labor, we generally do not code this service," Engstrom says. "We also don't code for a labor check when the patient goes to the hospital for observation and is then admitted for delivery."

On the other hand, you may find a way to be indirectly reimbursed for the labor check. The ob-gyn may perform the labor check, but as long as the patient does not deliver within 24 hours of admittance, you can include the reimbursement for the labor check in your codes for initial hospital care (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...). The important factor here is that the ob-gyn did not admit the patient for delivery. When that is the case, you can report the initial care separately from the global ob period.

Red flag: If the patient does deliver within 24 hours of admission, you should consider the labor check part of the global.

Example: A patient at 30 weeks presents to your ob-gyn 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. In this situation, you should include labor checks in the hospital admission fee (99221-99223). 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.