Ob-Gyn Coding Alert

NSTs monitor the fetus while labor checks assess the mother

If you are reporting 59025 when the ob-gyn checks to determine if a patient is in labor, you may not be coding accurately, even though the procedures are similar.
 
Ob-gyns often use a fetal monitor to determine if a woman is in labor. They use the same device for a fetal non-stress test (NST, 59025). But there are significant differences between the two procedures that require distinct approaches to coding.

Use 59025 for NST Only

To understand why you can't use 59025 for labor checks, first review what an NST involves. During the procedure, the ob-gyn monitors the fetal heart rate using external transducers. A "reactive" NST will show the fetal heart rate accelerate from the baseline 15 beats per minute for a minimum of 15 seconds at least twice during a 10-minute window, says Philip Eskew, MD, medical director of women and infants' services at St. Vincent's Hospital's Family Life Center in Indianapolis. If there are no accelerations after 20 minutes, the ob-gyn may attempt to induce a fetal response with acoustic stimulation through the mother's abdomen or a vibration that would awaken the baby or cause it to react to the stimulus. This stimulation might be repeated every five minutes for a maximum of two to three times, he notes. "If there are still no accelerations of the fetal heart rate, then it is interpreted as a 'nonreactive' NST."
 
"NST differs from 'routine' monitoring in that the patient is asked to mark fetal movements on the monitor strip, which the physician then interprets as generally reactive, nonreactive, and perhaps 'equivocal,' " according to Jeffrey Itkin, MD, FACOG, a former member of American College of Obstetrics and Gynecology's (ACOG's) Coding and Nomenclature Committee.
 
Therefore, when the ob-gyn performs an NST to determine fetal well-being, you should report 59025, Itkin says. According to Medicare's 2003 Physician Fee Schedule, the procedure carries 1.1 relative value units, meaning it's worth approximately $40.
 
On the other hand, an ob-gyn can perform an NST for a patient in the early stages of labor, Itkin points out. But remember that the patient must mark the fetal movements and the physician must interpret the strip and write (or dictate) a report, which must be entered into the patient record. "It is not enough to put the patient on the monitor and bill for an NST," Itkin adds.
 
"The NST is a valuable tool to be reassured that the baby is doing fine," Eskew says. "Spontaneous accelerations in response to an active baby are not only reassuring to the physician but often are an education to the mother: 'That's the baby moving? I have felt that before but didn't know it was the baby moving.' "

Include Labor Checks in Global

So the question remains: How do you get reimbursed for labor checks if you don't use 59025?
 
If the patient is at term, in labor and the ob-gyn admits her for delivery, the labor check is included as part of the global ob package (for example, 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care), says Peggy Stilley, CPC, office manager for Women's Healthcare Specialists, an Oklahoma University-based private ob-gyn practice in Tulsa.
 
On the other hand, the physician may perform a labor check and then request an NST to be reassured that the fetus is well before sending the patient home, Eskew notes. "Most NSTs are performed when the patient states that she has not felt the baby move very much or the mother is past 40 weeks 0 days," he adds. As long as the patient does not deliver within 24 hours of admittance, the reimbursement for the labor check would be included in the initial hospital care (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...), Stilley says. Because the ob-gyn did not admit the patient for delivery, he or she can report the initial care separately from the ob global period.
 
If the patient delivers less than 24 hours after admittance, however, you should again consider the labor check part of the ob global, Stilley adds. Consequently, you should not bill it separately.