Primary Care Coding Alert

Answer: There is no black-and-white answer for this question. Although there may be more than one way to code pregnancy care without delivery, knowing how to correctly code a situation does not guarantee payer agreement with the method you choose.

In general, when a baby is delivered by a physician other than the attending physician and the other physician intends to bill for that delivery, the attending can do one of two things depending on what the payer will accept. Option one is to code for global care (59400, routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) but add modifier -52 (reduced services) to indicate that a portion of the service was not performed. This method would work with either vaginal delivery or cesarean. However, since another physician will be billing for the delivery only, the attending physician should reduce his or her fee by the amount he or she would usually charge for performing only a delivery.

Option two would involve coding 59426 (antepartum care only; 7 or more visits) for the prenatal visits, billing for the hospital inpatient visits from the 99221-99239 section of CPT (both the initial care and any subsequent care), and billing for postpartum care (59430).

If the family practice physician is present during the cesarean delivery but does not participate in the surgery, only direct patient care for that calendar day can be billed. If there was participation in the surgery, there is the potential to bill for assistant-at-surgery services, reporting the procedure code with the -80 modifier (assistant surgeon). Note, however, that many insurers do not reimburse an assistant at cesarean unless the documentation clearly shows a complication during the surgery. In either option, the obstetrician who performed the cesarean will bill the appropriate delivery-only code.

I recommend option two because it is more descriptive of the services performed and is cleaner. Even so, the family practice physician will need to send in documentation with the claim. Information will need to be supplied to the payer detailing the exact services rendered by each provider and an explanation of why the cesarean proved to be medically necessary. And, if the physician who performed the cesarean is providing inpatient postpartum care, the insurance company probably will not reimburse the family practice physician for the same service (frequently referred to as the concurrent care issue).

In the first option, the family practice physician may have a problem billing a global vaginal delivery even with a reduced modifier when another physician bills for a cesarean. This inconsistency in billing is likely to play havoc with the insurers computer because usually the type of delivery on the global code should match the type of delivery finally performed. But even if the family practice physician decided to bill the cesarean global with a reduced-services modifier, the amount of the fee reduction would be difficult to calculate because the family physician would have no experience with this type of service. Note that the family practice physician should not be asking the surgical obstetrician what he or she charges for the service.

Answered by Melanie Witt, RN, CPC, MA, an independent consultant specializing in coding and documentation education based in Fredericksburg, Va., and former program manager for the department of coding nomenclature at the American College of Obstetrics and Gynecology.