Ob-Gyn Coding Alert

Question: The patient delivered twin A by normal spontaneous vaginal delivery (NSVD) at 18 weeks. Then the ob-gyn placed the cerclage for twin B. How should I code this?


California Subscriber


Answer: You need to know the status of twin A. Was Twin A born alive? If not, this is just an E/M service (probably 99212-99215) with cerclage placement as your procedure on that day (59320, Cerclage of cervix, during pregnancy; vaginal). The reason is this was a medical management of a miscarriage for twin A. The diagnoses will be 634.x2 (Spontaneous abortion; ...; complete) and 651.30 (Twin pregnancy with fetus loss and retention of one fetus; unspecified as to episode of care or not applicable). 

Remember: You should include modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the E/M service to indicate it was separate and significant from the cerclage placement.
 
If the physician also spent prolonged time with the patient during the time she was laboring, you can make a case for billing prolonged medicine services (face-to-face, either outpatient or inpatient, depending on the place of service) by reporting 99354-99355 or 99356-99357. Your ob-gyn must document the additional time as exceeding the typical E/M service amount by at least 30 minutes.

If twin A was born alive, you can code for the delivery at 18 weeks (59409, Vaginal delivery only [with or without episiotomy and/or forceps]) with the fetal outcome code (V27.0, Single liveborn) and the twin code 651.03 (Twin pregnancy; antepartum condition or complication) rather than 651.30 because even with only one twin in utero, this is still a twin pregnancy.
 
When you report the birth of twin B, you need to take into account when the second twin is born. If twin B is born less than 20 weeks and is not alive, you should report this just like twin A. If twin B is over 20 weeks (alive or not), you should report 59409 with the outcome code and twin code.