Ob-Gyn Coding Alert

Question: What do you code when a patient changes insurance carriers in the middle of her pregnancy but still continues with the same obstetrician? For example, lets say that she sees her doctor 4 times under insurance Plan A, but then switches to insurance Plan B, has 10 more antepartum visits and delivers at term with no complications. Both plans offer complete maternity benefits. Whom and with what codes do I bill?

Sue Skeens of Clarksville OB

Answer: The CPT has codes that can be used to reflect midterm changes in a patients insurance. First of all, when a patient changes health plans midstream in her pregnancy, neither insurance carrier wants to pay the complete global ob package. As a result, it wont work to bill for a global using 59400 or 59510. Instead, coding should accurately reflect the care rendered under each insurance plan. Heres how to do it:

Under Plan A, the patient was seen 4 times. That portion of her pregnancy should be reported to Plan A using 59425, the code for 4-6 antepartum visits. Since the delivery and most of her antepartum care took place under Plan B, coders have two billing options. You can bill Plan B using the global code (59400 or 59510) with a 52 modifier (Reduced Services) and subtract from the global fee the reimbursement already received from Plan A for those initial 4 visits. Or, you can bill 59426 (antepartum care for 7 or more visits) along with the delivery code that includes postpartum care (59410 or 59515). Either way, the coding accurately reflects the care rendered under each insurance plan. Reimbursement for services broken down in this manner should not be a problem providing that the insurance carriers have the 59425 and 59426 codes in their computer systems, and as long as they define their use in the same way the CPT does.

A Bonus Answer: When the patient changes obstetricians in the middle of a pregnancy but still has the same insurer, the coding should also be split in much the same way. But in this scenario, some insurance carriers may try to pay the global fee to just one physician and deny the other. If that happens, an appeal is warranted.