Ob-Gyn Coding Alert

Here’s what you should do when the babies are born on different days.

How should you report a twin cesarean delivery? The answer: 59510 with modifier 22 attached if the documentation supports significant additional work. But that may not always be the case. What should you do when twins are born on different calendar dates – or calendar years, in the case of the twins born on December 31^st and January 1^st. The solution is that you’ll need to adjust your twin delivery reporting depending on an insurance company’s preference.

Tackle these four tricky twin delivery questions and check with your contracts. You’ll be submitting picture perfect claims in no time.

1. How Should I Report Twin Delivery?

If a patient is having twins, most ob-gyns first attempt a vaginal delivery as long as the physician hasn’t identified any complications.

In this case, you should report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; multiple procedures) for the second.

Note: Both CPT^® and the American Congress of Obstetricians and Gynecologists (ACOG) recommend you use modifier 51 (Multiple procedures) for the second delivery. But you may encounter some payers who want to see modifier 59 (Distinct procedural service) instead. Other coders report appending modifier 22 (Increased procedural service) to the global delivery (59400) to account for the second delivery in cases where the payer does not permit separate billing for the additional delivery. When this instruction is in writing, you should follow it.

Best bet: Send a letter of explanation with the claim to avoid immediate denial by the claim processor. A simple form letter explaining the high-risk nature of multiple-gestation pregnancies will routinely go straight to medical review and save the hassle of denial resubmissions or lost reimbursement through write-offs, experts say.

2. What If the First Delivery is Vaginal, Second is Cesarean?

If the physician delivers the first baby vaginally but the second via cesarean, assuming he provided global care, report 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care) for the second baby and 59409-51 for the first. You should include one of the following twin diagnoses (O30-0--, Twin pregnancy). Also, you should report the outcome of the delivery by assigning a Z37 code  (e.g. Z37.2 (Twins, both liveborn).

For the second twin born by cesarean, use additional ICD-10 codes to explain why the ob-gyn had to perform the cesarean -- for example, malpresentation (O32.9XX0, Maternal care for malpresentation of fetus, unspecified, not applicable or unspecified) -- and the outcome (such as Z37.2).

3. What Should I Do for All Cesarean Deliveries?

When the doctor delivers all of the babies, whether twins, triplets, etc., by cesarean, you should submit 59510 with modifier 22 appended. Because the ob-gyn made only one incision, he performed only one cesarean, but the modifier shows that the physician performed a significantly more difficult delivery due to the presence of multiple babies. This can also depend on carrier. For instance, Colorado Medicaid allows you to bill for both babies, even though the physician makes only one incision, experts say.

Be sure to include a letter with the claim that outlines the additional work that the ob-gyn performed to give the carrier a clear picture of why you’re asking for additional reimbursement, as not all twin cesarean deliveries are difficult.

4. What if the Babies Come on Different Days?

Occasionally, multiple-gestation babies will be born on different days. For example, a patient is at 38 weeks gestation and carrying twins in two sacs. One membrane ruptures, and the ob-gyn delivers the baby vaginally. Two days later, the second ruptures, and the second baby delivers vaginally as well.

Here, you should report the first baby as a delivery only (59409) on that date of service. For the second, you should bill the global code (59400), assuming the physician provided prenatal care, on that date of service. The reason not to bill the global first is that you are still offering prenatal care due to the retained twin and you might want to consider adding a modifier 59 (Distinct procedural service) to the first delivery as it was performed at a different encounter. You will have to attach a letter explaining the situation to the insurance company. ICD-10 will be important to the payment. Be sure to use the outcome codes (for example, Z37.2).