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We are family practice and pt. came in for abdominal pain and uti, the nurse told her to get the sample for urine culture. Pt. delivered the baby in the washroom. Can I code this 59409 or not? Do I hav to use Modifier? Please help.
It's a family practice and not her obgyn office she comes for prenatal care. So the code would be 59409 as delivery code only. The obgyn office, would have to code her prenatal care only. It's a split bill.
Unless I'm reading this wrong, the patient delivered all on her own in the washroom. No, you cannot code delivery if the physician was not present for the delivery. Wouldn't be any different if she had delivered in the car on the way to the hospital, or at home without anyone present.
It is going to come down to how the actual delivery was documented. Was the provider called into the restroom to assist? If not, you are most likely going to end up with just the E&M code. I dont think anyone will get credit for the actual delivery unless its documented.
Does this mean you had a patient that didn't know she was pregnant?
I agree with the above, unless the physician was face-to-face with the patient delivering the baby, can't code a delivery code. If the Doc did an eval while waiting for transport the the hospital (assuming she didnt get up and go home or Walmart) then the physician could get an E&M
If the physician evaluated the baby, could he get a 99461? Just curious
99461---Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center