Ob-Gyn Coding Alert

The ob/gyn is often not the only physician providing obstetrical care to a patient. In situations involving more than one practitioner, coders need to know what their physician can bill for, what the other physician(s) can bill for and what can be billed concurrently. 

Obstetrical patients may opt to have their family practitioner (FP) handle the majority of their ob care, with the obstetrician handling a complicated labor or delivery only. In other cases, a high-risk pregnancy may be managed by the family practitioner, with input from an ob/gyn or perinatologist.

 

 

When the ob/gyn is the "second-string" physician in a pregnancy, billing of the global obstetrical package is handled by the FP. If all aspects of the pregnancy proceed with no complications, the family practitioner would use a single global code to report the service, either 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) or, when a vaginal delivery follows a previous cesarean delivery, 59610 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery).

 

 

Complications that occur during delivery alter the coding substantially -- including coding for ante- and postpartum care. An FP may have anticipated providing care from the day the pregnancy was diagnosed (i.e., V22.0, supervision of normal first pregnancy, or V22.1, supervision of other normal pregnancy) until the completion of postpartum care, but clinical conditions may appear during the birth process that alter that expectation.

Among the most common complications are breech delivery or malpresentation (652.xx), disproportion situations (653.xx), fetal distress (656.3x), obstructed labor (660.xx), umbilical cord complications (663.xx) and maternal hypertensive disorders (642.xx). 

When a complication arises and the FP requests the services of a colleague in ob/gyn, one major issue must be resolved -- which of the two doctors handles the care from that point forward? In some instances, the FP may prefer that the ob provide a consultation, simply reviewing the case and making recommendations. In many cases, depending on the complexity of the delivery, the ob would assume full care of the mother due to the ob's higher level of training. But when the specialist is invited to provide only a consultation, the family physician bills the global code 59400, and the ob assigns one of the initial inpatient consultation E/M codes (99251-99255), depending on the level of service provided. In many instances, the highest-level code, 99255, is reported because the presenting problems may be categorized as moderate to severe and the ob could easily spend the 110 minutes noted in that code's description. But, CPT also requires that this level of code be billed only if the physician has documented a comprehensive history and a comprehensive examination with high-complexity medical decision-making or has documented that more than half of the encounter time was involved with counseling or coordination-of-care activities with a complete description of those activities.

 

 

The coding becomes more complicated if the ob assumes care. The ob cannot bill the global code, but neither can the FP.  Instead, the ob will report the proper delivery code, and the FP will charge for ante- and postpartum care only.  Cheryl Christy, manager of University Perinatal Consultants, department of ob/gyn at Ohio State University in Columbus, says that with many patients, her practice will take over care near the delivery date, and bill for some antepartum visits, delivery and possibly postpartum care. "Of course this all depends on what the complications are," Christy says, "but it's rare for us to bill for global. Instead, we bill on a fee-for-service basis. The referring physician then does the same."

Among the codes the ob may use to describe the delivery without antepartum or outpatient postpartum care are 59409 (vaginal delivery only [with or without episiotomy and/or forceps]); 59514 (cesarean delivery only); 59612 (vaginal delivery only, after previous cesarean delivery [with or without episiotomy and/or forceps]); and 59620 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery). These codes, however, include inpatient postpartum care by the delivering ob. If the specialist performs a vaginal delivery and provides the outpatient postpartum care to the mother, use 59410 (vaginal delivery only [with or without episiotomy and/or forceps], including postpartum care) or 59614 (vaginal delivery only, after previous cesarean delivery [with or without episiotomy and/or forceps]; including postpartum care).

During a complex delivery like an emergency cesarean, the family physician may assist the ob or other specialist. In this case, the ob reports the delivery code, e.g., 59514, and the family practitioner reports the same delivery code appended with an -80 modifier (assistant surgeon) -- e.g., 59514-80.

Following delivery by another specialist, the ob and the FP coders must decide which of the antepartum and postpartum codes best describe the services rendered by their physician. "If the family physician has seen the woman throughout her pregnancy, 59426 (antepartum care only; seven or more visits) would be assigned," says Thomas Kent, CPC, CMM, president of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md. "And code 59430 (postpartum care only [separate procedure]) would be reported for outpatient care after delivery." 

If the ob/gyn took over care earlier in the pregnancy, say at 24 weeks, the FP might not have seen the patient as often. In this case, the FP would report 59425 (antepartum care only; four-six visits), and the ob/gyn would report the same code (59425) plus the delivery and postpartum care codes. If either physician conducted fewer than four antepartum examinations, each visit would be reported using the appropriate E/M code. Coders should also check with their carriers regarding requirements and guidelines in all instances when complications arise to avoid delays and confusion in billing.

 

 

Kent warns that hospital admission, labor management and inpatient postpartum care can create confusion about transfer of care during delivery. "Usually, these are included in the global codes and the delivery-only codes," he explains. "But when another specialist takes over during the delivery, this becomes confusing."

If an obstetrician is called in while the patient is in labor and subsequently delivers the baby, the ob may append the delivery code with modifier -52 (reduced services) to indicate that he or she did not provide admission or labor-management services. The family practitioner would report these services using inpatient hospital E/M codes (99221-99223), depending on the level of service provided, Kent says.  

"All of these possibilities can create confusion," he adds. "When a family physician calls in another specialist during delivery, it is vital that ob coders communicate closely with their counterparts in the FP's office. It's also important that the two talk to make sure each is reporting codes that complement the other. You want to avoid duplicate charges or oversights that will cause the carrier to reject either claim."  

Kent points out that family practices that perform deliveries often report the global code 59400 as a matter of course, as do obs. "It would be an easy mistake for both offices to simply assign 59400. But the insurer would flag it, and payment would be delayed. By keeping in close contact and making sure each office knows what the other is billing, you can minimize problems."

In Christy's cases, her physician is often called to the emergency department (ED) when the ob patient is sent there by her FP or ob, usually as the result of abnormal ultrasound findings. If Christy's perinatologist performs a second ultrasound in the ED, the patient's insurance gets billed for two ultrasounds on the same day. "One of those ultrasounds will get denied," Christy says, "and it's usually ours. If you do not take the time to coordinate with the others who will also be billing on the case, you are likely to be spending most of the time appealing."