Ob-Gyn Coding Alert

Question: We sometimes charge for a prolonged service when the ob-gyn spends hours with a woman with constant or intermittent face-to-face attendance. CPT says coders can use prolonged services codes with E/M codes or alone. In our large ob-gyn practice, we have both ob-gyns and certified nurse midwives (CNMs). At times, the CNM monitors a labor that ends in cesarean section. Since she attends the patient the entire time, we allow her to charge for prolonged services because she does not get reimbursement for the delivery. Is this correct?

Texas Subscriber

Answer: First, CPT does not state that you can use prolonged physician services alone. In fact, because the providing physician must go over the original service's expected time by at least 30 minutes, you can only use prolonged service codes with a CPT code that has time as part of its definition.
 
Obviously, then, you could not use prolonged services codes if you report surgery or global maternity care or a delivery. You can, however, use these codes when you report an E/M service.
  
In the ob situation in which the CNM manages the labor and the ob-gyn ends up doing a cesarean, the CNM may bill for her time by coding a hospital admission and subsequent care up to the point that the physician took over, because the CNM cannot bill for the global care.
 
Once you determine the level of E/M service, the CNM may also bill for prolonged inpatient service if the total time with the patient adds up to 30 minutes more than the typical time listed in the hospital care code. 
 
For instance, if the CNM reported 99222 for the hospital admission, she must spend at least 80 minutes with the patient before reporting the prolonged service code as well. Her claim must include the normal documentation that carriers require for the inpatient admission code, plus a description of services that required her constant attention, plus the documented time with the patient.
 
Remember, carriers might not reimburse prolonged services when labor progresses normally. The ob-gyn would step in when the baby gets stuck (perhaps needing vacuum extraction by the ob-gyn). In that case, and if the CNM does most of the delivery, you would not be able to report an E/M service for the labor management.
  
You may notice that CPT has an example of when to use the prolonged service inpatient code (Appendix C, Clinical Examples, page 412). In this example, the obstetrician deals with pre-eclampsia and premature labor. Since the admission is not for delivery, you should code for the hospital admission. The physician then documents the additional work required because of the patient's condition using the prolonged service inpatient code.