Primary Care Coding Alert

When your family physician (FP) shares maternity care outside a group-practice setting, you will have to abandon the global codes and enter the perplexing world of billing antepartum and postpartum services. Knowing what these packages include will ensure that you deliver the reimbursement your practice deserves.

Some FPs who offer maternity services may not perform deliveries. For various reasons, the FP may attend to a pregnant patient's prenatal and postnatal care and have another physician, such as an obstetrician (ob), deliver the baby.

"This is especially the case in rural areas where visiting the closest ob may require traveling 45 minutes to an hour," says Ginger Boyle, MD, a family physician practicing at Carilion Family Medicine Pearisburg in Pearisburg, Va. Consequently, a pregnant woman may see her local FP for pre- and postnatal care and periodically visit an ob who will handle the delivery, she says.

In this case, because the FP provides only partial maternity care, the obstetric care codes 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care), 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care), 59610 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesareandelivery) and 59618 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery) no longer apply, Boyle stresses. Therefore, you must break the care down and report only the FP's performed services.

Antepartum Care Starts Now

When dividing physicians'roles, you should pay particular attention to how you will report the before-birth services. CPT offers three coding options based on the number of prenatal visits. For one to three visits, you should report the appropriate E/M code per visit, according to CPT. If the FP sees the patient four to six times, CPT designates 59425 (Antepartum care only; 4-6 visits). Finally, 59426 ( 7 or more visits) describes seven or more antepartum visits. Because 59425 and 59426 include multiple visits, you should report either code only once. For instance, if the physician sees the patient for five visits, you should report 59425 once, not five times.

In all likelihood, if the FP assumes the primary and initial care and the ob handles some workup and the delivery, you will use 59426, Boyle says. For instance, the primary physician may see the patient for the first, monthly and weekly visits, and the delivering doctor may see the woman for the 18-to-20-week visit with ultrasound and the delivery. If any problems arise or the pregnancy goes past 40 weeks, the FP will turn over care to the delivering physician. "Of course, specifics will vary depending on the two parties," she adds. In this scenario, the FP would treat the patient for at least seven visits and report 59426. Boyle says that her practice has had no problem with insurers covering 59426 other than some initial questions when she first started using the code.

To avoid reimbursement hassles, you should first check with your carriers regarding how they want multiple antepartum visits coded, says Jean Ryan-Niemackl, LPN, CPC, content analyst for QuadraMed health information management division in Fargo, N.D. Some payers may allow you to bill an E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient) instead of the antepartum package. Reporting individual visits allows payment at the time of service rather than waiting until the patient delivers to total the number of visits and bill the corresponding code, Ryan says.

Get the Most out of the First Visit

When comparing these coding methods, you should consider whether the antepartum package includes the initial "pregnancy" visit. Because physicians often deem home-pregnancy tests unreliable and require a confirmation test at the first visit, you may wonder whether this first visit starts the ob package. The answer depends on when the physician establishes pregnancy. If the patient presents not knowing she is pregnant, do not include the visit in the antepartum care code. "It's OK to use an E/M code instead," Ryan-Niemackl says. On the other hand, if the patient knows that she is pregnant, even if she bases her knowledge on a home-pregnancy test, you should consider this the first ob visit, according to the American College of Obstetricians and Gynecologists.

Another way to identify whether the visit counts toward the ob record is to look at the visit's diagnosis. If the patient does not know she is pregnant and presents for a visit because she has missed her period, the FP will perform an examination and link the E/M, such as 99212-99215, to the diagnosis for missed period (626.8, Disorders of menstruation and other abnormal bleeding from female genital tract; other). In contrast, suppose a patient who has tested positive using a home-pregnancy kit presents to confirm her pregnancy. The FP takes a urinalysis at the beginning of the visit, confirms the pregnancy and begins an in-depth visit discussing prenatal care and concerns with the patient. In this case, the physician reports a pregnancy diagnosis, which means antepartum care begins, Ryan-Niemackl says. Consequently, you would count the visit in the antepartum care package.

Before you start tallying an ob visit for every patient who presents knowing she is pregnant, call your major carriers and see if they follow these rules. "Some insurers include the first visit in the antepartum package; some don't," Ryan-Niemackl says. Because policies vary extensively, the only way to ensure that you are capitalizing on accepted coding practices is to contact the payer, she emphasizes.

Ob Coordination Avoids Denials

In addition to dealing with payer variations, sharing maternity care creates a host of potential coordination nightmares. If the obstetrician uses a global code, such as 59400, the insurer may reject the FP's services due to duplicate billing. "Dividing who bills for what and who performed which services can be a headache," Ryan-Niemackl says.

Although you cannot create a set coding schedule that will work for every pregnant patient, you can try to hammer out variations in the beginning. For instance, when your FP agrees to share care with a delivery doctor, ask which specific services each plans on performing. Knowing who will provide what will help avoid the ob's billing for the FP's services, Boyle says. Then, contact the other physician's coders to discuss how you will handle coding without using the ob global codes. Extensive communication will put you both on the same page and should help you submit clean claims.

Postpartum Care Begins

In mapping out each doctor's role, you should consider the aftercare. "Obs usually are not interested in providing postpartum care to patients who already have primary-care physicians," Ryan-Niemackl says.

In addition, one of the main benefits of sharing maternity care is that the plan allows for continuity of care, Boyle says. "The patient already knows me and wants me to follow the baby," she says. So, the FP will probably assume all postpartum care and report 59430 (Postpartum care only [separate procedure]).

Some coders worry about using 59430 after a cesarean delivery because the patient requires more follow-up care than a patient who delivers vaginally. But an FP may provide this aftercare, usually at two and six weeks after delivery, Ryan-Niemackl says.

Don't Miss a Coding Opportunity

After the FP provides these visits, you may wonder how many more visits 59430 includes. "The Medicare Physician Fee Schedule doesn't specifically say how long postpartum care lasts," Ryan-Niemackl says. But most coding experts generally agree that the postpartum package lasts six weeks, she says. After that period and for any unrelated visits that occur before and after the delivery, you should use the appropriate E/M code.

For any visits during pregnancy that involve complications, you should report an E/M service(s). Per CPT, the maternity care codes refer to services normally provided in "uncomplicated maternity cases." So, for each visit that involves medical complications of pregnancy, you should assign an E/M code.