Ob-Gyn Coding Alert

Here's what to do when a provider wants to claim the delivery fee

Within and between groups, providers make specific arrangements ahead of time called coverage agreements. And before you apply a global code (such as 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) to your claim, you need to understand what kind of agreement your practice has in place.

Scenario: Two ob-gyns cover for each other and for other groups. For example, the ob-gyn at your practice provides all of the antepartum care, and the covering MD performs the delivery. How should you report this?

Confront These Types of Agreements

According to Glade B. Curtis, MD, MPH, FACOG, CPC, the presenter of -Ob-Gyn Coding and Reimbursement: Preparation for Accreditation- at The Coding Institute-s Ob-Gyn Coding and Reimbursement conference, you may encounter three types of arrangements--and how these arrangements work will affect how you code the global ob care.

You may have an informal agreement. In this situation, you code the global service under the ID of the ob-gyn on the patient's record--even though a covering MD performed the delivery. In other words, this is an -I-ll cover for you if you cover for me- arrangement. No money changes hands, because both providers agree things will even out in time. Warning: You need to check your state's statutes or regulations to see if this arrangement works.

Another agreement is locum tenens. In this case, the ob-gyn on record reimburses the covering MD, a temporary employee of the ob-gyn's practice. You-ll still report the ob global care under the ob-gyn's ID.

Yet another agreement is that the physician not part of the practice performs the delivery. In this case, the covering MD codes for the delivery, while you report the antepartum and postpartum care under your ob-gyn's ID. Note: You-ll need a letter of explanation to alert your payers the ob-gyn has this arrangement.

Smart: -If the coverage agreement is in writing and agreed upon before the actual services are performed, there are less chances of problems occurring later,- says Cheryl A. Lewis, CPC, office manager at ZIA OB/GYN LTD. in Yuma, Ariz. -We alerted our insurance carriers to the coverage situation, and they agreed it is easier   billing-wise to handle these situations in the manner we outlined. Some of the carriers actually reduce the allowed amounts when the services are -carved out.- -

Prepare for Snags Now

Sometimes you may have a dispute over who deserves the delivery compensation fee. When this happens, you have two choices:

Option 1: You can separately report each component of the global ob care. In other words, you-ll report the antepartum care (either 59425, Antepartum care only; 4-6 visits; or 59426, - 7 or more visits), the delivery of the placenta (59414, Delivery of placenta [separate procedure]), episiotomy repair (59300, Episiotomy or vaginal repair, by other than attending physician) and postpartum care (59430, Postpartum care only [separate procedure]).

Option 2: Or you can report the ob global service with modifier 52 (Reduced services) appended to 59400.

When Medicare assigned a value under the Resource- Based Relative Value Scale (RBRVS) for global ob package code 59400, they valued the components of the package as a percentage of the total work needed to provide complete ob care, Curtis says. In other words, they broke this code down as follows:

- Antepartum care is 41 percent of the work
- Admission H&P and labor management is 36 percent of the work
- Vaginal delivery is 15 percent of the work
- Postpartum care (includes inpatient and outpatient visits) is 8 percent of the work.

You can guesstimate your reduced services reimbursement accordingly, because your payer will likely deduct the percentage that your ob-gyn did not perform.

Bottom line: Before you apply the global code to your claim, you need to understand whether the covering provider will charge for his portion of the service.

Editor's note: Want to know more? You can order conference materials and look for information regarding the 2008 ob-gyn coding conferences at www.codingconferences.com.