Ob-Gyn Coding Alert

Question: When do I use the E/M codes 99201-99205 and 99212-99215 for an outpatient hospital setting as opposed to an observation code for labor and delivery when the patient has not delivered and is not admitted to the hospital?

North Carolina Subscriber

Answer: The observation codes (99234-99236) imply that the patient has a problem that you are not sure warrants admission to the hospital, but they also imply
that you will keep her awhile to be sure. The observation codes can only be used when the physician has seen the patient to admit her and has documented the three key components in the chart (history, exam and medical decision-making there is no time factor for observation status). Outpatient services to rule out labor, for example, could be reported instead if the physician kept the patient for a short time only.

Prolonged services (99354-99355 for outpatient prolonged service) can also be billed in addition to the outpatient E/M codes if the patients condition warranted the additional time. For instance, if the examination of the patient was documented as 99214 (detailed history or exam with moderate level of medical decision making) but the patients condition was such that the physician spent two hours with the patient, you might be able to justify billing for one hour and 35 minutes of prolonged service (must be face-to-face time, but not continuous) based on the CPT guidelines for billing prolonged services codes. This means additional coding using 99354 for the first 60 minutes and 99355 for the remainder of the time (you may not round up the 35 minutes to two units of 99355).

Remember, however, that many insurance companies will not pay extra for ruling out labor on a full-term patient, but will give additional reimbursement for problems when the patient is preterm or is being observed for a complication.