Primary Care Coding Alert

Delivering babies may represent a significant portion of a family practices business. In many cases, coding and billing is a straightforward issue. But when complications arise during a delivery, and a family physician calls in another specialist to assist or take over care, assigning the appropriate codes may pose a major challenge.

CPT 2000 provides specific sets of codes for reporting a wide range of services that may be applied during delivery. Professional coders need to be familiar with how those codes should be applied under which circumstances especially when delivery is anything but routine.

Using Single, Global Codes

When prenatal care, delivery and postpartum care progress with no complications, family practice coders assign a single code to describe the full spectrum of services provided. This code is 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care). In addition, CPT provides an additional global code to be assigned when a previous cesarean delivery is performed. This code is 59610 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery).

Note: Two global codes are provided for current cesarean deliveries as well. Although family practitioners seldom provide these services, code 59510 (routine obstetric care, including antepartum care, cesarean delivery, and postpartum care) and 59618 (routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery) are recommended.

Unfortunately, complications often occur during delivery, which may alter the coding scenario substantially including coding for ante- and postpartum care. A family physician may have anticipated providing care from the day the pregnancy was diagnosed (i.e., V22.2 [normal pregnancy, pregnant state, incidental]) until the completion of postpartum care, but clinical conditions may appear during the birth process that alter that expectation.

Complications during birth happen fairly frequently, says Ron Nelson, president of Health Services Associates Inc., a family practice in Freemont, Mich. What you expect to be routine seldom turns out that way.

Among the most common complications, he adds, are breech delivery and extraction (763.0), other malpresentation, malposition, and disproportion during labor and delivery (763.1), maternal anesthesia and analgesia (763.5), abnormality in fetal heart rate or rhythm during labor (763.82), prolapsed cord (762.4), other compression of umbilical cord (762.5), maternal hypertensive disorder (760.0) or maternal injury (760.5).

Coding for Complications

When a complication arises and the family physician requests the services of a colleague, Nelson says, one major issue must be resolved. When an obstetrician or other specialist is called upon, the question revolves around which of the two doctors provides the direct care from that point forward. In some instances, the family physician may prefer that the obstetrician (OB) provide a consultation, simply reviewing the case and making recommendations. In other situations, the OB would assume full care of the mother.

This decision would be made depending on the complexity of the delivery, he adds. In most cases, it is a standard-of-care question. Because the obstetrician has a higher level of training in this clinical situation, its probable that he or she would take over.

Thomas Kent, CPC, CMM, president of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md., agrees that it is more likely for the specialist to take over the delivery. Ive not seen many cases where the family practitioner calls in an OB simply to provide a consultation. If the delivery has become that complicated, it generally requires the OB to assume care.

In those rare circumstances when the specialist is invited to provide only a consultation, the family physician bills the global code 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care), and the specialist would assign one of the evaluation and management codes from the initial inpatient consultations section of CPT, 99251-99255 (new or established patient), depending on the level of service provided. In most instances, the highest-level code, 99255, would be used because the presenting problems could be categorized as moderate to severe and the OB easily could spend the 110 minutes noted in that codes description.

Using Component Codes

The coding situation becomes more complicated if the OB assumes care, says Nelson. The family physician coder can not assign the global code, but must look at the appropriate component codes. The obstetrician will report the proper delivery code, depending on the circumstances.

Among the codes the OB may use to describe the delivery without antepartum or outpatient postpartum care are 59409 (vaginal delivery only [with or without episiotomy and/or forceps]); 59514 (cesarean delivery only); 59612 (vaginal delivery only, after previous cesarean delivery [with or without episiotomy and/or forceps]); and 59620 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery). If the specialist performs a vaginal delivery and provides the postpartum care to the mother, 59410 (vaginal delivery only [with or without episiotomy and/or forceps] including postpartum care) would be assigned.

Note: Code 59410 also would be assigned by a family physician who did not see the patient during the antepartum period, but who provided the delivery and postpartum services described. For instance, a woman may have moved to a new area just before the birth of her child.

During a complex delivery like an emergency C-section, the family physician may provide assistance to the OB or other specialist, Nelson points out. If the OB simply provided consultation services, the family practice coder would assign the appropriate inpatient consultation code (99251-99255). More likely, however, the family physician actually would assist during the surgery, he says. In this instance, the family practitioner would report the delivery code appended with an -80 modifier (assistant surgeon) e.g., 59514-80.

Following delivery by another specialist, family practice coders then must decide which of the antepartum and postpartum codes best describe the services rendered by their physician. If the family physician has seen the woman throughout her pregnancy, CPT code 59426 (antepartum care only; seven or more visits) would be assigned, says Kent. Code 59430 (postpartum care only [separate procedure]) would be reported for outpatient care after delivery.

If, for some reason, fewer than seven visits occurred during the prenatal period, 59425 (antepartum care only; four-six visits) would be assigned. If fewer than four examinations were conducted, each would be reported using the appropriate evaluation and management (E/M) code.

Of course, coders would be well advised to check with the carriers regarding their requirements and guidelines in all instances where complications arise to avoid delays and confusion in billing.

How to Code Hospital Admit and Labor Management

Kent warns that a common area of confusion surrounding the transfer of care during a delivery involves hospital admission, labor management and inpatient postpartum care. Usually, these are included in the global codes and the delivery-only codes, he explains. But when another specialist takes over during the delivery, this becomes confusing.

If an obstetrician is called in while the patient is in labor and subsequently delivers the baby, the OB may append the delivery code with modifier -52 (reduced services) to indicated that he or she did not provide admission or labor management services. The family practitioner would then be justified in reporting these services using inpatient hospital E/M codes (99221-99223), depending on the level of service provided, Kent says.

All of these possibilities can create confusion, he adds. When a family physician calls in another specialist during delivery, it is vital that coders communicate closely with their counterparts in the obstetricians office. Its also important that the two talk to make sure each is reporting codes that complement the other. You want to avoid duplicate charges or oversights that will cause the carrier to reject either claim.

Kent points out that family practices that perform deliveries often report the global code 59400 as a matter of course, as do obstetricians. It would be an easy mistake to make for both offices to simply assign 59400. But it would be flagged by the insurer and payment would be delayed. By keeping in close contact and making sure each office knows what the other is billing, you can minimize problems.

Coding Separately for Hospital Admission Generally, when a delivery is routine and no specialists are called in to assist, family physicians would not bill hospital admission in addition to the global obstetric codes. There is, however, one exception to this rule, says Thomas Kent, CPC, CMM, president of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md. A physician usually admits a patient in labor under the assumption that she will deliver within 24 hours, he says. In these cases, the admission is included in the global code, and you would not report a separate hospital admission code. If the patient does not give birth within 24 hours, however, you may be able to bill the admission using the hospital inpatient service codes, 99221-99223, in addition to an obstetrics code. You would assign this only once, since these are per-day codes. As always, coders should check with their carriers to determine local policy. In addition, the patient record should include clear documentation that indicates when the patient was admitted, the duration of labor and when the delivery of the baby occurred.