Ob-Gyn Coding Alert

Question: If an ob patient beyond 15 weeks transfers to our practice, are we supposed to bill her as a new patient?


Tennessee Subscriber
Answer: The answer depends on how you bill the payer for the services your ob-gyn will provide.

For example, if another physician reports the visits prior to a transfer of care, your payer may well decide that you must itemize your services by breaking them out into antepartum care (59425, Antepartum care only; 4-6 visits; or 59426, ... 7 or more visits) and delivery plus postpartum care.

In this situation, you shouldn't look at whether the patient is new or established to your practice because CPT values the antepartum codes based on the assumption that you provided one new patient level-five visit as well as additional level-three visits.

The same rule applies if the payer allows you to bill the global service. The patient's first visit is comprehensive, regardless of whether the patient is new or established to your practice.
 
In a transfer-of-care situation in which the patient is clearly pregnant and another practice has provided her with care, you should never report the first visit using an E/M code, because the ob-gyn isn't diagnosing the pregnancy. Your ob-gyn instead assumes the pregnancy care.

Keep in mind, an exception might be Medicaid because many state programs want you to itemize each visit using an E/M code.