Try These Tips When Payers Dont Play by the Rules
Published on Sat Dec 01, 2001
No matter how accurately a coder adheres to CPT and CMS (Medicare) guidelines, some carriers ignore conventional reimbursement rules. After reading the July 2001 Ob-Gyn Coding Alert article "One Pregnancy, Two Doctors: Coding Correctly for More Than One Practitioner Prevents Denials," Jonathan Sheard, CA, CPA, FCCA, FIMI, business analyst for the Department of Family and Community Medicine at the University of Texas Health Science Center in San Antonio, wrote with a unique reimbursement problem related to his state Medicaid program.
"We are neither obstetricians nor gynecologists, but we provide ob services in the course of running our family practice residency program," Sheard says. He reports that the state Medicaid system will not pay for 59409 (vaginal delivery only [with or without episiotomy and/or forceps]) when one physician handles ante- and postpartum care and another handles delivery. Instead, Texas Medicaid will only cover 59410 (vaginal delivery only [with or without episiotomy and/or forceps]; including postpartum care) for a normal vaginal delivery even if postpartum care is not offered by the same physician.
"Yet if we have not provided the full scope of postpartum care," Sheard says, "code 59410 would not be appropriate to bill other providers for the same service. Furthermore, if our physicians do not provide any postpartum care at all, any use of the 59410 code is inappropriate."
The July article stated that 59409 and similar codes "include inpatient postpartum care by the delivering obstetrician." Sheard wonders if there are any strategies the practice can try with his state carrier to clarify which physician is doing what work, code correctly and ensure fair reimbursement to all parties involved.
Melanie Witt, RN, CPC, MA, an ob/gyn coding expert and independent coding educator, advises practices what to do when a payer doesn't play by the accepted rules of coding. "When a payer chooses not to follow either the CPT or Medicare standard for whatever reasons, we always advise that you get the instruction that is contrary to the standard in writing. This ensures that you are not left 'holding the bag' should the payer change its policy at a later date," Witt says.
In Sheard's case, he is dealing with a Medicaid program that, like most state programs, does not abide by the coding standards set forth in CPT or by Medicare (these rules are the same for obstetrics). All of the ob delivery codes, whether global or delivery-only codes, were valued under the Medicare Resource-Based Relative Value System (RBRVS), based on some assumptions about physician work. ACOG was instrumental in obtaining higher physician work relative value units (RVUs) for these codes by defining for CMS the amount of work involved for each code, including a description of all services for each code. [...]
