Ob-Gyn Coding Alert

Think you can handle situations where a pregnant patient moves out-of-state mid-pregnancy?

Prepare for coding your ob-gyn's services up to the date of the patient's move depending on how many antepartum visits the physician provides -- either one to three, four to six, or seven or more.

Scenario: Your ob-gyn sees a pregnant patient for only one to three antepartum visits. How should you report this?

Solution: You need to report the appropriate E/M codes for payment.

First visit: For the first ob visit, don't automatically look at a level-four established patient visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity), says Janine Snyder, billing supervisor at Desert Women's Health Care in Henderson, Nevada.

You won't have a set E/M code for the patient's first visit. Your patient could be new to the practice, or the first visit may meet the criteria for a level-five established visit. Therefore you should look to the entire code series (99201-99205 for new patients, 99211-99215 for established patients) as possible options.

Second and third visits: Your coding options are more limited for visits two or three. Medicare values the follow-up visit as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), so this code is your best bet for each of these visits in the absence of documented problems.

Heads up: In some rare circumstances, such as when the patient has absolutely no problems during the visit, however, the documentation might support reporting only 99212 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 10 minutes face-to-face with the patient and/or family) for each visit.

If the patient's pregnancy is without complication, your diagnosis would be either V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy).

Watch out: Because you do not have a specific antepartum code for one to three visits and have to report E/M codes, payers sometimes will deny these claims and tell you to "include in the global." You are "forced to appeal these decisions," Snyder says. Explain to the payer that you cannot report a global code because you are no longer the patient's OB care provider.

Scenario: Your ob-gyn sees a pregnant patient for four to six antepartum visits. How should you report this?

Solution: Four to six visits means you-ll be flipping through your book to the maternity care and delivery section -- particularly the antepartum codes.

You should report 59425 (Antepartum care only; 4-6 visits), which represents the total services rendered by your ob-gyn. This means that you-ll report only one unit of this code.

Rare case: Sometimes, you-ll encounter a payer that instructs providers to report a separate E/M service for the first ob encounter, says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis. "You would need to have this in writing from your payer, and then you would need to meet the criteria of at least four additional visits to report 59425."

Note: Your diagnosis will be the same (V22.0 or V22.1) unless the patient has any problem or complication.

Scenario: Your ob-gyn sees a pregnant patient for more than seven or more visits. The patient then leaves your practice. How should you report this?

Solution: You-ll find more variation in your coding choices for this scenario -- but one thing is certain: you should avoid reporting global codes at all costs. You can report a global code only if your ob-gyn provides all a patient's maternity care. Because you-re talking about a patient who leaves the practice before delivery, codes 59400-59622 do not apply.

Option 1: For seven or more visits, CPT has a specific code: 59426 (... 7 or more visits). "I would report one unit of 59426," Snyder says. You would include diagnosis codes V22.X-V23.84, as appropriate.

Option 2: Some payers may ask you to report each visit separately. Good idea: Ask the insurer what "separate" means.

"Separate" may mean reporting 59426 along with a list of the dates. This is why you should definitely keep track of a patient's prenatal visits by noting the date the ob-gyn sees the patient.

The payer may also want you to report the appropriate E/M code for each visit, but that isn't likely.