Ob-Gyn Coding Alert

Hint: You must clinically valid reason for the extra time.

If your ob-gyn attempts to bill a full 9938X-9939X and compliantly bill this to Medicare with G0101, Q0091, and G0513, then you could run into real claim trouble.

Check out this question submitted by Ob-gyn Coding Alert subscriber, Karen Acton, CPC, COBGC, a coding associate in Oregon.

Get the History Behind New Prolonged G Codes

On January 1, 2018, CMS added to new G codes to report prolonged physician services which you can report for ob-gyns — so long as the ob-gyn documents and meets the criteria. The copayment and deductible are waived for these codes:

• G0513 (Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service))
• G0514 (Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)).

When to use them: You should use these codes for wellness visits that are covered by Medicare and are especially time consuming. The provider must meet the threshold time for the visit and half of the prolonged services time. “As CMS has confirmed that they will use the CPT® time rule for these new prolonged preventive services codes, the full time of the wellness visit must be met, before adding the time for the prolonged code,” says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M.

Timeframes for these prolonged services are as follows:

• Less than 15 minutes is not reported separately.
• G0513 x 1: 15 - 44 minutes
• G0513 x 1 and + G0514 x 1: 45 - 74 minutes (45 minutes–1 hour 14 minutes)
• G0513 x 1 and + G0514 x 2: 75 - 104 minutes (1 hour 15 minutes - 1 hour 44 minutes)
• G0513 x 1 and + G0514 x 3: 105 - 134 minutes (1 hour 45 minutes - 2 hours 14 minutes).

Apply the 2018 Final Rule for these Other Wellness Services

CMS published in the 2018 final rule the time for each wellness service that must be exceeded, and these appear in the table below:

Beware: The application of the prolonged preventive services codes only applies to the services described by the G codes listed in the above table. These codes could not be used to account for additional non-covered preventive medicine service.

Example: The ob-gyn performs a Pap and pelvic examination on a Medicare patient, which takes the amount of time stated in the table (up to 26 minutes total), but then goes on to take a history, discussed preventive issues of concern to the patient, and does an examination of the abdomen, thyroid, lungs, etc.

Solution: These services would be billed to the patient using the preventive medicine codes (9938X-9939X), which are not covered by Medicare. Therefore, the time spent in performing these non-covered services could not be reported using the prolonged preventive services codes G0513 or G0514, Witt says.

Support the Additional Time

According to the guidelines published by National Government Services (NGS), the contractor for Illinois, Minnesota, and Wisconsin, “The medical record must include information to support the medical necessity of this additional time; there must be a clinically valid reason for this extra use of time in performing the preventive service. Please note the additional time may only be spent by the provider performing and billing the preventive service; these services are not subject to incident to billing. We would not expect the use of these codes to be routine or frequent in any given practice; the codes represent relatively unusual circumstances requiring the provider to spend a prolonged period of time in direct-patient contact.”

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