Primary Care Coding Alert

Depending on whether a family practitioner provides antepartum care only, delivers the baby, just offers postpartum care or does a combination of all three changes the coding picture. Codes also depend on how much antepartum care is provided and on the type of deliveryvaginal, cesarean or vaginal after a previous cesarean delivery.

To provide an idea of what is possible in the scope of a family practice, consider the following:

A family practitioner (FP) provides antepartum care for three visits, turns the delivery over to an ob/gyn but oversees the postpartum care for his established patient, a 30-year-old first-time mother with slightly high blood pressure. The FP would code 99212 (office or outpatient visit for the evaluation and management of an established patient, with a problem focused history, a problem focused examination and straightforward medical decision making) or a higher level evaluation and management (E/M) code, if there were any complications, for each of the three visits and 59430 (postpartum care only [separate procedure]).

Greg Schnitzer, RN, CPC, CPC-H, CCS-P, audit specialist with the office of audit and compliance with the University of Pennsylvania in Philadelphia, says that confusion may arise if the ob/gyn uses a global obstetric care code, 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy and/or forceps] and postpartum care), even though he or she only did the delivery, not the ante- or postpartum care. Then there would appear to be a duplication of services between the family practitioner and the ob/gyn.

A patient sees her family practitioner five times prior to the birth of her baby and again for postpartum care. This time the family doctor would bill 59425 (antepartum care only; 4 to 6 visits), along with 59430 for the postpartum care. If she had made seven or more antepartum visits, 59426 (antepartum care only; 7 or more visits) would be used instead of 59425.

The American College of Obstetricians and Gynecologists (ACOG) says, however, that if the total number of antepartum visits exceeds 13 due to a high-risk condition, the additional visits may be reported using E/M visits, e.g., 99212, added onto 59426 for each extra visit.

Is 59400 the Only Code to Use for Global Services?

If the family practitioner provides the ante- and postpartum care, along with a vaginal delivery, he or she simply codes for global maternity care 59400. That will include an unlimited number of antepartum care visits.

That would seem simple enough but Jean Ryan, CPC, billing compliance analyst for MeritCare Medical Center in Fargo, N.D., begs to differ. Responsible to several carriers, including Medicaid and Medicare, Ryan finds herself coding different ways for basically the same procedures depending on the carrier.

For instance, if the family doctor provides antepartum care for five visits, postpartum care and a vaginal delivery, he or she could code 59400 or 59425 with 59410 (vaginal delivery only [with or without episiotomy and/or forceps]; including postpartum care). She says that Medicaid prefers that each antepartum visit, no matter how many, be coded as an E/M service; the delivery coded as 59409 (vaginal delivery only [with or without episiotomy and/or forceps]); and the postpartum care coded separately with 59430, or as an alternative, 59410 may be substituted for the combination of 59409 and 59430.

Ryan warns that whatever combination is used as an alternative to the global code, make sure it equals the pricing of the global code.


Separate Codes Needed for New Family Doctor

A patient in mid-term moves and seeks the care of a new family practitioner after having gone to her original family doctor for a few antepartum visits. What will the new doctor bill if the first doctor has laid claim to some of the antepartum visits? Can the new family doctor bill for global care (59400) or does he or she have to code separately for each service, e.g., antepartum, delivery, postpartum?

Schnitzer says the new family doctor has to code separately for the antepartum care (59425, antepartum care only; four to six visits), delivery and postpartum care (59410) instead of using the global care code. A carrier will not pay for more than a global code, he says. But the question to ask is whether the pregnant patient has seen any other practitioner for antepartum care before coming to the family doctor mid-term. If she hasnt, then you can bill 59400.

More Than a Maternity Problem

If the patient comes in for a routine antepartum visit but also complains of a sore throat, the family doctor would code 99212 for an office visit. If a patient under antepartum care with a family doctor comes in exclusively for a condition not related to her pregnancy, such as an upper respiratory problem, again you would use an E/M office visit code (99214). But Ryan suggests you use the ICD-9 code 465.0 (acute laryngopharyngitis) instead of V22.2 (pregnant state, incidental). Using V22.2 may cause a problem when you are coding under a global package, she adds.

If a patient has a condition during the postpartum period which is unrelated to the pregnancy, such as an upper urinary tract infection, you may code for the E/M service (99212-99214) and 599.0 (urinary tract infection, site not specified) for the infection. On the other hand, says Barbara Cobuzzi, CPC, CHBME, a consultant with Cash Flow Solutions Inc., a medical billing and consulting firm in Lakewood, N.J., if the condition is something resulting from an episiotomy, for instance, that care falls under 59430.