Ob-Gyn Coding Alert

When a reimbursement claim has been denied, the appeals process can be frustrating. Detailed documentation is crucial to winning the appeal and getting the appropriate compensation.

Barbara J. Cobuzzi, MBA, CPC, president of Cash Flow Solutions, a medical billing and coding consulting firm in Lakewood, NJ, offered several successful appeals scenarios.

A high-risk pregnancy patient had 18 visits during the prenatal phase. A cesarean delivery was performed, and billed as 59510 (routine obstetric care including antepartum care, cesarean delivery and postpartum care). The practice also billed for six evaluation and management (E/M) visits, with various dates, depending on the documentation, using codes 99212- 99215 (office or other outpatient visit for the evaluation and management of an established patient [with various levels of history, examination and medical decision-making]). The carrier paid $1,600 for the global of 59510 and denied all the other charges.

The first steps in the appeals process, says Cobuzzi, were to get the records copied, write a simple letter explaining the complexity of the case and the reasons for the additional visits (outlined by date). We then went on to say that the standard for routine care is 12 visits, and therefore the payer was obligated to pay for the additional services. We were careful to indicate the medical necessity of the additional visits. (Please note that some payers say that 14 visits is the normal package, but I try to slant it toward the bottom of the range when trying to get paid for complex cases.)

In this situation, merely explaining the complexity of the case was enough to tip the scales in the practices favor.

In another example, a doctor was set to perform a precertified laparoscopic assisted vaginal hysterectomy (LAVH), using CPT 58550 (laparoscopy, surgical; with vaginal hysterectomy with or without removal of tube[s], with or without removal of ovary[s] [laparoscopic assisted vaginal hysterectomy])

Note: In CPT 2000, this code was renumbered from 56308.

While the doctor initially thought that this more conservative approach would be possible, upon doing the diagnostic laparoscopy, 49320, (laparoscopy, surgical, abdomen, peritoneum, and omentum; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) (formerly 56300), which is bundled into 58550, the doctor determined that he could not do the procedure via scope and converted to an open total abdominal hysterectomy (TAH) using code 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). Instead of billing 58550, the bill was for 58150 and 49320 (not bundled). The payer only paid for the diagnostic laparoscopy (49320) since 58150 was not pre-certified.

Again, says Cobuzzi, a letter to the payer indicated the order of events, [...]