Ob-Gyn Coding Alert

2 factors determine whether you should code a regular antepartum visit

If a new patient arrives at your practice in later stages of pregnancy, should you use an initial-visit E/M code or an antepartum visit (four-seven prenatal visits) and delivery only?

The choice depends on two factors - the patient's previous care or lack thereof, and payer recommendation, according to the American College of Obstetricians and Gynecologists (ACOG).

No History of Care? Use a Reduced Global Maternity Code

If the patient had no history of care prior to coming to your practice, ACOG supports using a global maternity code (such as 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) with modifier -52 (Reduced services).

You should use the reduced services modifier because the package includes 13 antepartum visits. At 31 weeks, this new patient has only nine weeks to go until delivery. Therefore, the ob-gyn will provide far fewer antepartum visits.

"You begin her prenatal course in your practice. You would work off the global concept until after delivery, even if she had no prenatal care prior to visiting you," says Harry Stuber, MD, FACOG, an independent gynecologist based in Cookeville, Tenn.

Keep in mind: "Some carriers may request a breakdown of the charges," says Brenda Dombkowski, CPC, a coding specialist at Obstetric-Gynecology & Infertility Group in Cheshire, Conn.

In this case, you should itemize each antepartum visit through a higher E/M service level. You would use E/M codes 99201-99205 for a new patient and 99212-99215 for an established patient - if the ob-gyn sees the patient for fewer than four visits. If the ob-gyn sees the patient for more than four visits, use the antepartum-care-only codes (59425, Antepartum care only; 4-6 visits; or 59426, ... 7 or more visits) and try adding modifier -22 (Unusual procedural services) along with documentation indicating the high-risk issues, Dombkowski says.

And, you should report the code for delivery plus postpartum care (for example, 59515, Cesarean delivery only; including postpartum care).

Note: Because the patient did not receive the normal rounds of antepartum visits, she would be considered a high-risk pregnancy with a diagnosis of V23.7 (Insufficient prenatal care), Dombkowski says.

Deciding Frequency of Antepartum Visits Depends on Patient's Risk

Occasionally, the ob-gyn may be unsure of whether a patient had antepartum care visits with another provider.   According to Wisconsin Medicaid, "If the recipient is unable to provide this information, the provider should assume the first time he or she sees the recipient is the first antepartum visit."

Afterward, the ob-gyn should determine the frequency of subsequent antepartum office visits by the woman's individual needs and risk assessment. Because this patient's lack of prenatal care puts her into a high-risk pregnancy category, the ob-gyn may request many more visits thereafter.

"You might very well have visits at 31, 33, 35, 37, 38, 39, 40 and 41 weeks and then delivery, which would involve eight prenatal visits, and you'd bill a global code (such as 59400)," Stuber says.

Check With Carriers for One Prenatal Visit Before Delivery

The pregnant patient saw your ob-gyn only once before delivery. CPT specifies that you should report an E/M code (99201-99205 for a new patient to the practice, or 99211-99215 for an established patient). You should then code the delivery with the postpartum care with 59410 (Vaginal delivery only [with or without episiotomy and/or forceps]; including postpartum care).

However, some carriers may still ask you to bill the global maternity code (59400, 59510, 59610, 59618) with modifier -52.

Transfer of Care? Then Antepartum May Not Be Global

If the patient transferred to the practice, you should code this like any other transfer-of-care situation - you should report only the codes for the care provided by your practice, because another doctor will code for the care that he provided.

Think of it this way: When a patient transfers in the middle of the pregnancy, the global code no longer applies. You should code only for those parts of the pregnancy care the ob-gyn handles. "Start counting the visits, and when she delivers, you'll code the antepartum by count and then the appropriate delivery and postpartum codes," says Charline Wells, a coding and compliance auditory for Valley Obstetrics & Gynecology, Washington.

Both antepartum care codes (59425, Antepartum care only; 4-6 visits; and 59426, ... 7 or more visits) link to the patient's condition at the time the ob-gyn rendered the service. If the ob-gyn supervises a normal pregnancy, the diagnostic code will be either V22.0 or V22.1. 

Note: This same rationale applies when the patient changes insurance. The ob-gyn provided all of the care to the patient but must break out the care so that each insurer receives claims for the services that were their financial responsibility. 

Again, you would code the diagnosis the same - supervision of a normal pregnancy (V22.0, Supervision of normal first pregnancy; V22.1, Supervision of other normal pregnancy; or V22.2, Pregnant state, incidental). 

If there are complications or if the ob-gyn supervises a high-risk pregnancy without current complications, you can select a code from the ob chapter of CPT or from the V23 category.

A few payers may insist that you report the service globally if you did the delivery. If so, you should use the global code (such as 59400) with modifier -52 to indicate that some of the services are being billed to a different insurer.

Don't Include Initial Visits With Global and Antepartum Codes

Some coders believe that when a patient transfers care to a new physician they should report a separate E/M service in addition to the code for the remaining antepartum care because the ob-gyn must perform a full exam and review her records.

If a patient transfers her ob care to a new physician, you should code either the antepartum-only code (59425-59426) or the global service with a reduced-services modifier if the carrier requests it.

Do not report an additional initial visit code, says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions, an Eau Claire, Wis., company that provides coding support, compliance review and contract coding to physicians across the country.

The relative values for the antepartum care and global codes already take into account that you will have a high-level new patient visit when the ob-gyn performs these services.