Wiki Billing NST w/ 99213,25

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smrobinson1128@gmail.com

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I have an OB patient with private insurance who is high risk. She is now starting NST's bi-weekly. I am billing a 99213,25 with proper dx codes for reason of high risk with an NST 59025.

1. If the patient has NOT had 13 antepartum visits yet, and all visits have been billed as 720, is the 99213 considered part of the global OB care?
2. If the patient HAS had 13 antepartum visits, and requires additional visits, is the second NST for the week reimbursable or is it considered part of global OB care?
 
Taking global maternity out of the picture to start. 99213-25 means there was a significant and separately identifiable E&M service besides the NST service. Please ensure there is a 99213-25 supported that is above and beyond the work associated with 59025.
1) "Billed as 720". I am not sure what that means. Is 720 some type of internal practice specific code or terminology used? Global maternity visits are typically coded s 0500F-0503F. Visits that are for global maternity care that are in the typical number of visits should not be billed separately.
2) You seem to be asking if the NST is reimbursable. If so, NSTs are not included in global maternity care. If the question is actually whether visits beyond 13 are billable, then yes. High risk or complicated pregnancies that require additional prenatal visits beyond usual, the additional visits are billable. Again, ensure there was actually a visit, and not just testing performed.

With private payors, it is best to check their specific policies. For example:
file:///C:/Users/clhei/Downloads/CC.PP.016.pdf
 
I apologize, the 720 is an internal code we use to signify that the visit is part of the global OB maternity care and not billable.

I understand that the NST is a covered service since it is not included in the global maternity care, however it is the separate E&M code of 99213,25 with the NST that I am questioning. Our patients are having 2 visits per week for their high risk status. Since weekly Ob visits are part of the global maternity care, should we be billing a 99213,25 in addition to the NST for both visits during that same week? I would think that the first visit of the week would be considered global maternity care (since normal OB visits are weekly at 36 wks for the remainder of the pregnancy) and then the second visit for the week is acceptable to bill the OV and the NST since it is outside of the normal routine visits. The first visit of the week we would bill out the NST only, then the second visit of the week, we would bill out the E&M 99213,25 in addition to the NST. All visits where the NST is completed, the doctor/NP is seeing the patient to make sure all complications related to her high risk diagnosis' are stable.

My understanding is, whether the patient is High Risk or not, if she is attending her routine antepartum visits (once monthly up to 28weeks, then bi-weekly 28-36 weeks and then weekly at 36wks) then these visits are considered global maternity care. Once the patient is having antepartum visits outside of the routine 13 antepartum visits, then we can bill a E&M code with a qualifying High Risk dx code.

Is this correct?
 
smrobinson1128@gmail.com said:
I apologize, the 720 is an internal code we use to signify that the visit is part of the global OB maternity care and not billable.

I understand that the NST is a covered service since it is not included in the global maternity care, however it is the separate E&M code of 99213,25 with the NST that I am questioning. Our patients are having 2 visits per week for their high risk status. Since weekly Ob visits are part of the global maternity care, should we be billing a 99213,25 in addition to the NST for both visits during that same week? I would think that the first visit of the week would be considered global maternity care (since normal OB visits are weekly at 36 wks for the remainder of the pregnancy) and then the second visit for the week is acceptable to bill the OV and the NST since it is outside of the normal routine visits. The first visit of the week we would bill out the NST only, then the second visit of the week, we would bill out the E&M 99213,25 in addition to the NST. All visits where the NST is completed, the doctor/NP is seeing the patient to make sure all complications related to her high risk diagnosis' are stable.

My understanding is, whether the patient is High Risk or not, if she is attending her routine antepartum visits (once monthly up to 28weeks, then bi-weekly 28-36 weeks and then weekly at 36wks) then these visits are considered global maternity care. Once the patient is having antepartum visits outside of the routine 13 antepartum visits, then we can bill a E&M code with a qualifying High Risk dx code.

Is this correct?
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You are correct about the approximate timing for the visits, but the issue becomes whether the payer will accept billing 2 visits per week for a high risk patient. By using the modifier -25 on the E/M you are indicating that the visit involved separate and significant work than the work included in the NST. Normally if the time spent was to go over the NST result with the patient and discuss how the pregnancy is going so far, I would consider that included in the NST. If the patient is actually being scheduled for an office visit twice a week because she is high risk, you could bill for the extra visit, but you will probably get a denial from the payer as she has not yet delivered. You would then wait until she delivers to appeal the denials and hopefully get paid for the extra visits. The other option is to wait until delivery and then bill the extra visit or add a modifier -22 to the global code. This, of course, has the disadvantage of having the payer apply the "timely filing" reason for the denial. Just make sure the extra visit is in fact due to her high risk pregnancy and not just to discuss the NST results and related topics to the NST.
 
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