Ob-Gyn Coding Alert

Question: Our practice's midwife went to the hospital to see an ob patient who had not been admitted but was in triage in labor and delivery for approximately eight hours. She is 36.6 weeks pregnant. Our midwife went into the hospital and was face-to-face with her for approximately three hours, interpreting the strip, assessing the patient, prescribing and discharging her. How should I code for this time? We used diagnosis code 644.0x (Threatened premature labor).

Massachusetts Subscriber

Answer: You could report an observation/discharge service on the same day with 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date), but all three key components of exam, history and medical decision-making must be documented in the record because these codes have no time component as the outpatient E/M (99201-99215) codes do.

If the criteria cannot be met, you can bill the outpatient E/M (9921x) code that most closely represents the service (assuming the patient was not being checked for labor status at term and 36 weeks, six days is coming pretty close which is generally considered part of the global service). If time was then also documented and the face-to-face attendance was required because of the patient's condition, you might also be able to make a case for the prolonged services codes +99356 or +99357 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service) as well.