Ob-Gyn Coding Alert

Question: I have a maternal fetal medicine (MFM) doc that does an inpatient evaluation and management (E/M) (99221-99223, 99231-99233 with 25 mod) along with a fetal non-stress test (NST) (59025-26). Medicaid of Alabama is denying the E/M and BC as bundled with the NST, even when the E/M has a 25 mod. Is this just a combination that cannot get paid?

Alabama Subscriber

Answer: First, check their policy manual for any specific rules, as these two services are not bundled, but it may be that this MD’s documentation does not support the E/M as being separate and significant or that the purpose of the visit was the interpretation of the NST only. Make sure those facts are secure.

Assuming the patient was not admitted for delivery by this provider, and you have the necessary documentation, you should appeal. If she was admitted for the treatment or evaluation of complications during the pregnancy which did not lead to a delivery within that episode of care, you should be able to get both paid, and a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the E/M would be correct along with modifier 26 (Professional component) on 59025. Just be sure the 59025 (Fetal non-stress test) represents an actual NST and not simply labor monitoring — which is a big difference in the documentation.