Wiki OB questions/profee

[j0yLynN13]

Dr. A provides antepartum care - 59426
Dr. A admits patient for delivery
Patient requires a C-section (done by surgeon - Dr. B -outside of practice/not under same TIN) and surgeon did NOT dictate the assist at surgery
Dr. A continues to see patient on rounding
Dr. A does post partum care (that starts after discharge from hospital) - 59430

What can Dr. A charge for the ProFee visits he/she provided to the mother on the OB floor?

Example:
01/01 Dr. A H&P
01/02 Dr. B C-section/unplanned obstructed labor
01/03 Dr. A progress note
01/04 Dr. A discharge summary

Thank you

 

[cmcevoy]

I would say:
1/1 Dr A - Admission 99221-99223
1/2 Dr B - C-section 59514
1/3 Dr A - Subsequent hospital 99231-99233
1/4 Dr A - Discharge 99238-99239
If you receive a bundle denial for the admission, subsequent or discharge charge, you may need to inform the payer the delivery was done by outside provider.

 

[nielynco]

I would say:
1/1 Dr A - Admission 99221-99223
1/2 Dr B - C-section 59514
1/3 Dr A - Subsequent hospital 99231-99233
1/4 Dr A - Discharge 99238-99239
If you receive a bundle denial for the admission, subsequent or discharge charge, you may need to inform the payer the delivery was done by outside provider.

The problem here is that 59514 includes the admission which Dr. B did not do. So from a strictly CPT perspective Dr. A should bill 59514-56 and Dr. B would bill 59514-54, the fact they were done on different days would not impact this. As 59514 does not include any postop visits, Dr. A can bill on 1/3 and 1/4 as you have suggested.

 

[cmcevoy]

The problem here is that 59514 includes the admission which Dr. B did not do. So from a strictly CPT perspective Dr. A should bill 59514-56 and Dr. B would bill 59514-54, the fact they were done on different days would not impact this. As 59514 does not include any postop visits, Dr. A can bill on 1/3 and 1/4 as you have suggeste

Interesting, thank you for your feedback. What about the fee? Would the fee for 59514-56 be the same as 59514-54? Do payors pay accordingly or do you get denials for service already paid?

 

[csperoni]

In my system, the fee (amount charged to insurance) would not change. The reimbursement will be reduced with -56 or -54. Generally with splitting the global, the insurance will take the entire payment that would typically be allowed and split that between the providers. Different carriers could have differing percentages depending on policy or contract, but ballpark is -54 about 70% payment; -56 about 10% payment.
Again, depending on the carrier, but typically if a claim has already been incorrectly paid, the insurance will recoup the payment and then issue correct payment(s).
I will note splitting the global surgical package this way with -56/-54 also requires an official transfer of care, which may or may not have occurred. The Medicare global surgery booklet contains a lot of the details. https://www.cms.gov/outreach-and-ed...oducts/downloads/globallsurgery-icn907166.pdf

EDIT: I also want to mention that many practices have arrangements (strictly reciprocal or otherwise) in which Dr. A & Dr. B have previous agreed that Dr. A will bill global maternity for this type of situation.