Primary Care Coding Alert

Many family physicians (FPs) provide antepartum care for pregnant patients with chronic conditions because the FP is familiar with the patient's problem. Although the obstetrician (OB) will deliver the baby and provide postpartum care, the FP monitors the condition and sees the patient for routine prenatal visits. But coding for antepartum care is not always as straightforward as just using maternity codes 59425 (Antepartum care only, 4-6 visits) or 59426 (... 7 or more visits). Various coding options exist depending on how the patient's chronic condition may affect labor and delivery.

When the FP sees a pregnant patient one to three times only, he or she codes those visits with the appropriate-level E/M office visit code (99201-99215). "The coding changes when the patient has a chronic condition," says Victoria Jackson, owner and executive director of OMNI Management Inc., a medical practice management firm in Lake Forest, Calif.

When treating a pregnant patient with a chronic condition, an FP may provide different types of antepartum care:

1. Chronic condition that has to be monitored by the FP. Some pregnant patients have chronic conditions that will not necessarily complicate labor and delivery but need to be monitored closely. When the patient comes in to have her chronic condition checked, use the E/M office visit codes (99211-99215) for these visits and the diagnosis code for the condition. For example, a pregnant patient with severe asthma continues seeing her FP so the doctor can monitor her condition. Code these visits with the appropriate E/M office visit codes and 493.xx (Asthma) for the chronic condition. It is not necessary to use the diagnosis code for pregnancy in this case because the FP is treating a separate problem that will not affect the pregnancy.

"Although the patient is pregnant, if the physician is checking up on her condition and not providing the routine antepartum care services, you can't use the antepartum codes," says Joan Hubball, FNP, nurse practitioner at the Fernald Center in Waltham, Mass. But if the patient comes in for routine antepartum care, and the doctor also separately treats the chronic condition, use the antepartum care code and the appropriate-level E/M code appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). "Usually, however, when the chronic condition will not affect labor and delivery, the physician will not combine those visits," Hubball says.

2. Chronic condition that may complicate labor and delivery. When a pregnant patient with a chronic condition that could affect the pregnancy visits her FP for routine antepartum care, you should use 59425-59426. You should also report the diagnosis code for the chronic condition and/or the appropriate code from the 640 series indicating complications related to pregnancy (640-648). For example, the physician determines that an established patient's hypertension may complicate labor and delivery and must be monitored closely because it can be a precursor to toxemia or pre-eclampsia. The FP provides the patient's antepartum care and also manages the hypertension during the routine antepartum visits. The patient visits the FP regularly before labor and delivery. Code 59426 with 642.2x (Hypertension complicating pregnancy, childbirth, and the puerperium; other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium).

3. Chronic condition and high-risk problem that will complicate pregnancy. In these cases, the FP may provide complete antepartum care. Coders should report the antepartum care code and the appropriate-level E/M office visit code. Append modifier -25 to indicate that the office visit is separate from the antepartum visit. For example, a patient with diabetes, who is at high risk for gestational diabetes and pregnancy-induced hypertension, sees the FP once a week. During each visit, the physician provides routine antepartum care. He or she also administers blood sugar and urine tests and closely monitors the patient's blood pressure to treat the chronic condition and the pregnancy-induced hypertension. Code 59426 and 99214 appended with modifier -25. "If the condition will affect the pregnancy, the patient will be visiting frequently," Jackson says. "As long as the doctor is addressing how it will affect both the mother and the child, they can use the E/M codes with the antepartum codes."

Many OBs use the pregnancy global code 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care), which includes antepartum care, even when the antepartum care is provided by the FP. "This can appear to insurance companies as duplicate billing," Hubball says. "If they see that the OB's code included antepartum care, they won't reimburse the FP for antepartum care." But when the FP provides antepartum care in place of the OB, the OB should not use the global code. Some OBs say that care of the maternity patient in the hospital before delivery is antepartum care. However, standard coding protocol interprets antepartum care as an out-of-hospital service. The FP should work closely with the OB to make sure he or she does not use the global maternity care code if antepartum care is provided by the FP.

Carriers have different requirements for providing antepartum care to patients with chronic or high-risk conditions. Practices should contact the insurer as soon as they receive the patient's insurance information, preferably before the antepartum visits begin. Explain to the payer the patient's medical condition and what kinds of treatment or E/M management will most likely be required.