Ob-Gyn Coding Alert

When an ob patient enters the hospital for delivery, and that delivery takes 24, 48, 72 or more hours, just how much of her care during that time is included within the global package? Is the entire time regarded as part of global or are certain services and procedures billable separately from global care as evaluation and management (E/M) care?

Scenario: An elderly primigravida with chronic pain and hypertension unrelated to the pregnancy is admitted to the hospital at 6 a.m. Tuesday for the purpose of inducing labor. The ob/gyn brakes the patients amniotic sac and administers an IV of Pitocin. After the patient is on the Pitocin drip for 14 hours, the contractions are still minor and not accelerating. The ob/gyn takes the patient off the Pitocin IV, then restarts the IV several hours later, for another 20 hours. At 3:30 a.m. Thursday the physician decides to conduct a c-section. The pregnancy is delivered at 8 a.m. Thursday without complications to mother or baby.

Whats In and Whats Out With Global Billing?

After hearing the above patient scenario, Laurie Castillo, MA, CPC, of Physician Coding and Compliance Consulting a Manassas, Va.-based medical practice consulting firm, concluded that everything before the last 24 hours prior to delivery was billable outside of the global package. Castillo explains: Global ob care is considered everything within the range of normal. When antepartum care goes above and beyond what is considered normal, especially with inpatient services, those services can be billed separately.

The rule of thumb is that everything prior to the last 24 hours before delivery potentially is billable outside of global. The key then is to identify the levels of evaluation and management (E/M) care and document medical decision-making to make a good case for a hospital admission that did not result in a delivery for several days.

Castillo brakes down the individual services and diagnoses that apply in the above case. The billing sequence would begin with an inpatient admission and then describe the reasons for each procedure and medical decision up until the time of delivery.

CPT codes 99221-99223 (initial hospital care, per day, for the evaluation and management of a patient which requires these three key components; ranging from a detailed to a comprehensive history, a detailed to comprehensive examination and medical decision making that is straightforward or of low complexity to high complexity) would apply for the patients admission. The coder also would need to include the reason for admission. In this case, the doctor felt that the patients hypertension was severe enough to warrant an induction of labor. Though pre-existing and not gestational, the hypertension would be coded as a complicating factor, using ICD-9 [...]