Ob-Gyn Coding Alert

Coding expert offers surefire advice for your obstetric coding questions

Reporting obstetrics may be something you do every day, but that doesn't mean it's easy.
 
Accurate, authoritative answers to troublesome coding questions will help you avoid costly errors that lead to low reimbursement or claims denials.
 
The following questions were raised by ob-gyn coders across the country and answered by Melanie Witt, RN, CPC, MA, who provides the answers based on her experience as an independent coding education consultant and former American College of Obstetrics and Gynecology (ACOG) program manager for its coding education department.
 
What's Included in the Ob Package?

Question: What services are considered part of the global maternity package (for example, routine dip urinalysis, blood draw, etc.)?

CPT includes a definition of services that are part of  the global package in the "Maternity Care and Delivery" section immediately before 59000. The guidelines explain what is included in antepartum, delivery and postpartum services.
 
Many coders are confused because some payers may try to include some of the tests performed as screening during pregnancy in the global package. The CPT definition states that a routine chemical urinalysis is included - it does not specify a dipstick, and it does not specify under microscopy or another method. The definition simply states that a routine urinalysis is included, and this is a chemical test. If that is what you are doing, regardless of the method used, it is included in the obstetric global package.
 
Any other test that the ob-gyn performs on a patient during her pregnancy is most likely excluded from the global package under CPT guidelines. There may be complications, however. For example, a physician was getting very nervous because he had been sued previously, so he decided to do an alpha-fetoprotein (AFP) test on all pregnant patients. The insurance carriers saw the AFP being billed regularly for all patients and notified the physician that they were no longer going to reimburse for that service. They stated that the AFP was now recognized as part of his routine obstetric package care, and they were rolling it in. Unfortunately, this is the view of many payers.
 
If you consistently bill for things when there appears to be no good medical indication for the particular patient, the insurer will tend to view the service as part of your global package and refuse to pay for it. You are not performing the service because the patient needed it; you are doing it on all patients, regardless of need. Ensure that the tests you do outside of the routine urinalysis are medically indicated for the specific patient.
 
Drawing blood to send a sample to the laboratory is not included as part of your global service. If you are doing it because the patient needed to have some lab work done, the insurer should reimburse for it.
 
When you are dealing with any payer regarding obstetric services, you should spend some time in advance reading your contract or agreement with that payer. Billing for services that your contract or agreement clearly states are included and are not going to be paid separately won't do you any good. You can take this information to your physicians who may have signed off on the contract to suggest they renegotiate the next contract to exclude specific services from the global because you do not perform them on every patient.

Don't Forget the Hospital Services

Question: What hospital charges can the physicians report for obstetric patients?

You can bill hospital services outside of the obstetric global in a couple of instances. You could report the admission history and physical and any subsequent care if the ob-gyn admits the patient for a complication of pregnancy. The caveat is that payers usually will not reimburse you for a service that takes place within 24 hours of the delivery. The 24-hour period is open to debate because payers tend to go by calendar dates and not hours in a day or number of hours prior to delivery. Generally, if you admit a patient on day one because of premature labor contractions that you were trying to stop and you deliver on day three, the carrier should pay days one and two outside the package. It would not reimburse separately for day three because that was the date of the delivery.
 
Bill separately for procedures - other than labor management - the physician performs while the patient is in the hospital. Most carriers consider induction of labor part of labor management, and hospital staff, not the physician, usually starts the IV. You can use the IV infusion codes if the physician personally starts the IV, sits with the patient the entire time, and documents that time. If the ob-gyn admits the patient to the hospital for a condition and then discharges her without delivery, you can bill for the admission, the subsequent care and the discharge day management.

Add More Diagnosis Codes for an Accident

Question: When an obstetric patient is in a car accident, what diagnosis code should we use with an ultrasound or fetal non-stress test (NST)?

The answer depends on what is wrong. For example, an obstetric patient involved in an automobile accident may be admitted for observation, even if she has no complaints or signs of injury. In that case, you would use V71.4 (Observation following other accident), V22.2 (Pregnant state, incidental) and an E code for the automobile accident. These three codes will explain the situation.
 
On the other hand, if a patient comes in following an automobile accident and has an injury, this probably will affect the pregnancy. You would call it a complication affecting the management of the pregnancy. Report 648.93 (Other current conditions classifiable elsewhere; antepartum condition or complication) in this case because she has not delivered. List all of the non-ob chapter codes that represent the injuries the obstetrician is treating. If the patient is seen in the emergency department (ED) and the ED staff takes care of that part, you would not report those services. You would indicate that there is a potential here for conditions elsewhere, etc., but you are not taking care of that part. You may still use the E code.
 
If the accident affects the fetus in any way, such as decreased fetal movement or a change in the fetal heart rate, there is a code in the ob chapter that you use. In that case, do not use the E code - you cannot use it with the fetal category codes or any other code outside the ob chapter because it assigns the problem to the mother and that is not the situation. You are saying something is wrong with the fetus.
 
If the physician feels that the injuries are not impacting the pregnancy at all, but he or she is taking care of those injuries, you are going to bill the injury codes, V22.2 and the E code.

Know When to Call the First Ob

Question: When a patient comes in for a pregnancy test prior to her first ob visit, should we use a pregnancy diagnosis for this visit because we know by the end of the visit that she is pregnant? Or should we use V22.1 or V22.0?

The global obstetric package starts when the physician initiates the ob record. The problem arises when the patient comes in and you confirm pregnancy during that visit with a urine pregnancy test. There are two schools of thought. One is that you should report 626.8 (Disorders of menstruation and other abnormal bleeding from female genital tract; other). This is the reason the patient came in. She missed a period. She may be pregnant, and you need to confirm that, so you are going to submit it as such.
 
The ICD-9 rules, however, say you should code what you knew at the end of the visit. That is why some coders say if you know she is pregnant at the end of the visit, you have to bill V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy). That means the visit gets included in the ob global package when it shouldn't be, unless you also have initiated the ob record at that visit.
 
If the first visit's purpose is simply to confirm that the patient is pregnant, you could just have her come in and do the urine test. Don't bill an E/M visit, because you know the carriers bundle the two services together. If the visit's only intent is to confirm the home pregnancy test, you could just bill for the test and schedule her for her first ob visit at that time.
 
Follow the ICD-9 coding rules because those are the established standards. Therefore, if at the end of the visit you have done a urine test and it is positive, you have to say she is pregnant. But you should not report both a missed period and V22.0 or V22.1 on the claim form. You normally would bill an E/M service, if you have documented one. The E/M service, however, is probably not going be a high- level service because all you are doing is the urine test and maybe asking the patient some questions.