Using Initial E/M Visits for New Pregnant Patients? Think Again
Published on Mon Aug 30, 2004
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 [...]
