Ob-Gyn Coding Alert

Question: How do you correctly code for multiple births by cesarean? Weve tried appending modifier -51 to 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care), thus charging full price for the first baby and 50 percent for each additional infant, but reimbursement is poor. We also tried appending modifier -22 but received only the regular fee [for 59510]. Any suggestions?

Carol Byrd, LVN, CCE
Doctors Office for Women
Newport Beach, CA

Answer: Unfortunately, there is no CPT code for multiple births. Therefore, modifier -22 is still the best option for commercial carriers and it is also the most correct option. This is because the physician did not perform more than one cesarean, but rather removed more than one fetus from a single incision. In coding a second cesarean as you previously described, you were in effect saying that you provided more than one global service. At a minimum, coding for more than one cesarean delivery would require reporting the cesarean only code, 59514 or 59620, with both a modifier -51 (multiple procedures) and a modifier -52 (reduced services). Modifier -52 would be needed because the delivery-only codes include inpatient postpartum care, a service that would not be provided more than once for this patient. One way you can increase the chances of optimum reimbursement using the modifier -22, however, is to enclose a KISS (Keep it Short and Simple) letter with your operative report. Otherwise, payers may be tempted to ignore the modifier -22. A cover letter, while not a panacea for fair payment, may go a long way toward getting payers to acknowledge the extra services provided in a multiple delivery.

Create a form letter in which you fill in the blanks. Use three or four short, simple statements to help insurance reviewers understand the exceptional circumstances that caused you to ask for the additional fee.

For example, a KISS letter in this case might say:

This claim is for a patient who had three children during the same cesarean delivery. Because the CPT does not include a code for multiple births, we are appending modifier -22 (unusual circumstances) to 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care). A multiple birth by cesarean is more complicated than a single delivery and requires substantially more time for the physician as the attached operative report clearly shows. [If the documentation supports the presence of a second physician, mention that as well.] Therefore, we are asking for an increase of 30 percent above our usual fee.

Sample of Modifier -22 (KISS Letter):

Patient Name Insured ID # ________
Date of Service _______Procedure Code(s) ________ Fee _______
Increase in standard fee requested ______%
Diagnosis Code _____________Provider
Provider Statement:
Provider signature

The usual fee for modifier -22 is 20 to 30 percent over and above the usual and customary amount. For both commercial and Medicaid payers, be sure to use the correct diagnosis code for multiple birth outcome (V27.2-V27.7).