Ob-Gyn Coding Alert

Here’s what to do if you’ve already seen the patient 7+ times.

Prepare for coding your ob-gyns services up to the date of the patient’s move depending on how many antepartum visits the physician provides -- either one to three, four to six, or seven or more.

1-3 Visits Mean Office E/M Codes

Scenario: Your ob-gyn sees a pregnant patient for only one to three antepartum visits. How should you report this?

Solution: You need to report the appropriate E/M codes for payment.

First visit: For the first ob visit, don’t automatically look at a level-four established patient visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity...).

You won’t have a set E/M code for the patient’s first visit. Your patient could be new to the practice, or the first visit may meet the criteria for a level-five established visit. Therefore you should look to the entire code series (99201-99205 for new patients, 99211-99215 for established patients) as possible options.

Second and third visits: Your coding options are more limited for visits two or three. When Medicare and ACOG were developing the relative value units for antepartum care,  the follow-up visit was estimated to be a 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), so this code is your best bet for each of these visits in the absence of documented problems.

Heads up: In some rare circumstances, such as when the patient has absolutely no problems during the visit, however, the documentation might support reporting only 99212 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 10 minutes face-to-face with the patient and/or family) for each visit.

If the patient’s pregnancy is without complication, your diagnosis would be either V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy).

Watch out: Because you do not have a specific antepartum code for one to three visits and have to report E/M codes, payers sometimes will deny these claims and tell you to “include in the global.” You are forced to appeal these decisions. Explain to the payer that you cannot report a global code because you are no longer the patient’s OB care provider.

4-6 Visits Mean Antepartum Code

Scenario: Your ob-gyn sees a pregnant patient for four to six antepartum visits. How should you report this?

Solution: Four to six visits means you’ll be flipping through your book to the maternity care and delivery section -- particularly the antepartum codes.

You should report 59425 (Antepartum care only; 4-6 visits), which represents the total services rendered by your ob-gyn. This means that you’ll report only one unit of this code.

Rare case: Sometimes, you’ll encounter a payer that instructs providers to report a separate E/M service for the first ob encounter. You would need to have this in writing from your payer, and then you would need to meet the criteria of at least four additional visits to report 59425.

Note: Your diagnosis will be the same (V22.0 or V22.1) unless the patient has any problem or complication.

7+ Visits May Mean Variation

Scenario: Your ob-gyn sees a pregnant patient for more than seven or more visits. The patient then leaves your practice. How should you report this?

Solution: You’ll find more variation in your coding choices for this scenario -- but one thing is certain: you should avoid reporting global codes at all costs. You can report a global code only if your ob-gyn provides all of a patient’s maternity care. Because you’re talking about a patient who leaves the practice before delivery, codes 59400-59622 do not apply.

• Option 1: For seven or more visits, CPT^® has a specific code: 59426 (... 7 or more visits). You would include diagnosis codes V22.X-V23.84, as appropriate.
• Option 2: Some payers may ask you to report each visit separately. Good idea: Ask the insurer what “separate” means.

“Separate” may mean reporting 59426 along with a list of the dates. This is why you should definitely keep track of a patient’s prenatal visits by noting the date the ob-gyn sees the patient. Keep in mind that 59426 was valued based on the assumption that it would include a maximum of 10 visits.  Therefore, if the number of actual visits exceeds this, and because 59426 is a “surgical” code, the modifier 22 might be appropriate to add if the documentation supports significant additional work.

The payer may also want you to report the appropriate E/M code for each visit, but that isn’t likely.

ICD-10: When your diagnosis code system changes, you’ll have new options for those codes mentioned in this article:

• Code V22.0 expands into four options: Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester), Z34.01 (... first trimester), Z34.02 (... second trimester), Z34.03 (... third trimester).
• Code V22.1 will include the four new codes listed above as well as four more: Z34.80 (Encounter for supervision of normal pregnancy, unspecified, unspecified trimester), Z34.81 (... first trimester), Z34.82 (... second trimester), and Z34.83 (... third trimester).