Ob-Gyn Coding Alert

Draw the line between diabetes before pregnancy and gestational diabetes.

So you know that a diabetic pregnant patient requires services that are separate from the global package and a higher level of management skill — but does your patient’s payer? You need to get your documentation in order, so you can demonstrate how your ob-gyn is essentially taking over the diabetes management.

Step 1: Point Out the Difference

The biggest difference between a diabetic and non-diabetic ob-gyn patient is that the diabetic patient must constantly communicate with her doctor, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

Pregnant diabetic patients fall into one of the following categories, each of which requires substantial physician management:

1. Established diabetes type I or II, controlled: Ob-gyns can monitor these patients with more ease than uncontrolled diabetes patients. The reason is because these patients are already familiar with the necessary methods of managing their pre-existing diabetes, and the patient is able to control her insulin levels at all times by being compliant with her disease monitoring.

2. Established diabetes type I or II, uncontrolled: Patients who cannot control their pre-existing diabetes through medication and diet will need additional counseling and monitoring. Pregnant women with uncontrolled diabetes tend to have larger babies, thus cesarean sections are more common.

3. Gestational diabetes, controlled or uncontrolled: Gestational diabetes can often go undetected well into the pregnancy. Patients new to diabetes require significant counseling and education to establish a controlling regimen of care throughout the pregnancy.

Step 2: Build a Case for Extra Office Visits

Extra office visits required for a diabetic ob-gyn patient are common sticking points when you’re seeking reimbursement from carriers.

Why? Ob-gyns see diabetic pregnant patients with much more frequency because of risks to the mother and fetus. Typically, the obstetrician will see the patient every other week for the first seven months, and then even more frequently during the last two months of pregnancy. In some cases, during the last two months of pregnancy, the patient may go to the hospital for a fetal non-stress test (59025-26, Fetal non-stress test; professional component) every other day.

Important: The global ob package does not include an office visit for diabetes management. You should report this as an E/M encounter. For instance, 99212 (Office or other outpatient visit ... established patient, which requires at least two of these three components: problem focused history; problem focused examination; straightforward medical decision making) is generally the standard for the non-global E/M visit. But if the doctor wants to bill for a 99213 (… which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) or 99214 (… which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity), he will need to provide extra medical justification for the higher levels and subsequent visits.

If the patient has other problems, such as uncontrolled diabetes requiring hospitalization or training, then document time spent with the patient and bill for the higher level visit using the time rule, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey.

One strategy: Some ob-gyns working with high-risk patients (and maternal-fetal specialists in particular) have negotiated for high-risk global packages with their payers. They bill for an all-inclusive global and get paid more and are saved the hassles of trying to convince the carrier to pay for the extra E/M visits, Cobuzzi says.

Step 3: Examine the Extra Testing Problem

You’ve got the extra office visits figured out, but what about additional tests required to manage the pregnancy?

The following tests are often required as part of managing a diabetic ob-gyn patient:

• hemoglobin A1C (82820, Hemoglobin-oxygen affinity [pO2 for 50% hemoglobin saturation with oxygen)
• alpha-fetoprotein (AFP) (82105, Alpha-fetoprotein [AFP]; serum or 82106, ... amniotic fluid)
• ultrasound (76805-76828; [depending on method and approach])
• electronic fetal monitoring (59051, Fetal monitoring during labor by consulting physician [i.e. non-attending physician] with written report; interpretation only) when performed by the non-attending physician. (When performed by the attending physician, you should include this service as part of the global package.)
• fetal non-stress test (59025)
• test for spina bifida (such as, 82013, Acetylcholinesterase; 82105 or 82106).

The nitty gritty: Your problem in reaping extra reimbursement for these services could stem from your diagnosis coding. You’ll find a code for diabetes with pregnancy in ICD-10’s ob-gyn chapter. But even when you report a second code to show the type of diabetes, some payers will not pay for any additional services because you have used a pregnancy code.

Step 4: Break Down Your ICD-10 Options

In ICD-10, you have specific gestational diabetes codes in category O24.4- (Gestational diabetes mellitus). But keep in mind that these codes may not be reported if the patient has only had a 1 hour GTT with an abnormal result. A 3 or 4 specimen GTT must be performed and be abnormal to substantiate a diagnosis of gestational diabetes. In addition, under ICD-10 rules, you would not report an additional code for long-term insulin use as the codes are specific enough already as to insulin or hypoglycemic drug control.

These codes are:

• O24.410 (Gestational diabetes mellitus in pregnancy, diet controlled)
• O24.414 (... insulin controlled)
• O24.415 (… controlled by oral hypoglycemic drugs)
• O24.419 (... unspecified control)
• O24.420 (Gestational diabetes mellitus in childbirth, diet controlled)
• O24.424 (... insulin controlled)
• O24.425 (… controlled by oral hypoglycemic drugs)
• O24.429 (... unspecified control)
• O24.430 (Gestational diabetes mellitus in the puerperium, diet controlled)
• O24.434 (... insulin controlled)
• O24.435 (… controlled by oral hypoglycemic drugs
• O24.439 (... unspecified control)
• O99.810 (Abnormal glucose complicating pregnancy)
• O99.814 (Abnormal glucose complicating childbirth)
• O99.815 (Abnormal glucose complicating the puerperium).

Step 5: Try Your Hand With This Example

So how should you link these diagnosis codes to your CPT^® codes? Learn from the following scenario.

Example: Your ob-gyn decides to perform a detailed ultrasound on a pregnant gestational diabetic patient whose diabetes is diet controlled. For this service, you would report 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation). You’ll link this procedure to O24.410 to reflect the gestational diabetes.