Ob-Gyn Coding Alert

Question: Our ob physician was asked by an orthopedic surgeon to be in attendance during ankle surgery on a pregnant patient. The ob physician monitored mom and baby during the surgery. He did non-stress tests (NSTs) and other monitoring throughout the surgery, which lasted one hour. How would we bill/code this?

Helen Grubb, CPC
Providence Hospital & Medical Centers
Novi, Mich.

Answer: This is definitely a situation in which the services of the physician should not be included in the global ob package. Unfortunately, there is no CPT code specific to monitoring a patient under anesthesia unless the physician billing is the anesthesiologist. You also do not want to report physician standby services (99360) because your physician provided services during the surgery.

Itemize what was performed. Code separately for each NST performed, using 59025 (fetal non-stress test). You will need to add modifier -26 (professional component) because the NST was performed in an inpatient setting and also add modifier -76 (repeat procedure by same physician). Your physician will need to be sure, however, that each NST performed is documented.

You say the physician performed other monitoring, but without more information about exactly what the physician did, you cannot pick a CPT code (assuming that one exists). For instance, while the physician may have performed fetal monitoring, you could not report 59050-59051 (fetal monitoring during labor by consulting physician ...) because these codes can be used only when the patient is in labor. But your physician is providing an inpatient evaluation and management (E/M) service, so you can use the subsequent inpatient hospital care codes 99231-99233 (subsequent hospital care, per day, for the evaluation and management of a patient), assuming the documentation reflects the care given.

Notice also that 99233 has a typical time of 35 minutes, so if time has been documented in the record, you can report this code. If the physician spends more than one hour with the patient you can also bill for prolonged physician services using 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour). CPT rules say you can bill this code when the typical time for the E/M service has been exceeded by 30 minutes. You will also note that this code directly references maternal fetal monitoring for high-risk delivery or other physiological monitoring for the first hour of prolonged service in an inpatient setting. So bill for the E/M service by listing 99233 and possibly 99356.

If you have a payer who will not accept coding the NST with an E/M prolonged physician service (and you need to add modifier -25 to the E/M codes to indicate that a significant and separately identifiable E/M service was provided), settle for the services (NST or E/M service) that best describe the majority of time spent with the patient. Remember, however, that you will need to support your claim with medically necessary diagnostic information, which means that one of the codes should be V23.8 (supervision of other high-risk pregnancy) (in this case, a patient undergoing surgery while pregnant).