Orlando Report: High Stakes for High-Risk Pregnancy
By Michelle A. Dick, senior editor, and Peggy Stilley, CPC, CPC-OBGYN, ACS-OB
In June, more than 1,800 coders and other medical professionals came together to celebrate medical coding and teach and learn coding excellence at the 16th National Coding Conference in Orlando, Fla. Hot topics, such as “Medicare’s Incident-to Rules,” presented by Hugh Aaron, MHA, JD, CPC, CPC-H, and the AAPC Legal Advisory Committee’s “Legal Trends and Issues,” hashed out a lot of pressing questions many coders have with constantly changing coding rules and regulations. All sessions were informative, but space limits us to focus on one. After all, we may enjoy the exhibitors, freebies, SeaWorld, the resort atmosphere, and CEUs that attending a national conference brings, but the bottom line of what we are seeking is coding knowledge.
High-risk pregnancies are complicated as they require more time and more clinic resources. Many times payers’ software does not allow proper adjudication, and contracting is sometimes inadequate. Although CPT® defines global care for uncomplicated pregnancy, it does not specifically address the issue for high-risk pregnancy. For the obstetrical global package, CPT® describes all services provided in a non-complicated case—including antepartum care, delivery, and postpartum care. Carriers do not always follow CPT® or American College of Obstetricians and Gynecologists (ACOG) guidelines. Always check with your payers to verify what services are covered and included, and what benefits are afforded to the patient.
High-risk indications include medical conditions with the mother, risk factors or potential risks, abnormality of the fetus, hospitalizations occurring outside the admission for delivery, and a need for consultation or intervention by physicians with additional training.
Note: Not every problem or issue renders a pregnancy high-risk.
If the admitting primary care physician does not perform the delivery due to complications requiring a Caesarian-section (C-section), the admitting physician may report:
- Prenatal visits (as appropriate)
- Initial hospital admit
- Prolonged attendance when medically necessary
- Assistant at C-section (on delivery only, code 59514-80 Cesarean delivery only; Assistant Surgeon)
- Hospital discharge
- Postpartum care (as appropriate)
- Concurrent/Co-management Care
For concurrent/co-management care, the general obstetrician (OB) seeing the patient for regular visits should document on the prenatal flow sheet and document in the notes who is co-managing the patient and for what medical reason. Specialists seeing the patient periodically for monitoring, ultrasound, lab, and other reasons should separately document services; not on the antenatal flow sheet. These services are outside of the global package.
To measure the movement of the fetus and heart rate and to monitor uterine contractions code 59025 Fetal non-stress test for non-stress testing (NST) services. To code the amniotic fluid index (AFI), use 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses to measure fluid.
Use codes 76818 Fetal biophysical profile; with non-stress testing and 76819 Fetal biophysical profile; without non-stress testing for biophysical profile (BPP) (physiologic test) of baby’s heart rate, muscle tone, movement, and breathing. Remember to add results of NST.
Ultrasounds do not include pre- and post-op elements and stand alone. Counseling, consultation and discussions with the patient are services in addition to the ultrasound. Modifier 51 isn’t appropriate as these services should not be discounted. Use of modifier 59 as directed in CPT® will eliminate the reduction while telling the payer the services were for separate fetuses.
For multiple gestations, code appropriately using CPT® codes: 76801, 76802; 76805, 76810; 76813, 76814; 76818, 76818-59; 76819, 76819-59; 76820, 76820-59; and 76821, 76821-59. Use documentation requirements as per the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the American Institute of Ultrasound in Medicine (AIUM) guidelines.
E/M Visits and Consultations
Consultations must meet request, render, and report requirements and establish the course of treatment for the patient. Evaluation and management (E/M) visits can be for new or established patients. E/M visits can be billed by time (> 50 percent counseling); however, they cannot be billed as such “I spent 40 minutes with patient of which > 50 percent of the time was spent counseling the patient about …” Counseling, education, answering questions, etc., are billable E/M services. A modifier is not required with an ultrasound, unless the payer tells you to get this in writing. Payers may toggle between allowed diagnosis codes; check with carriers for correct code usage.
Chapter 11 codes take priority over codes from other chapters. It is the physician’s responsibility to state the reported condition is not complicating the pregnancy (per ICD-9-CM coding guidelines). Codes from other chapters can be used in conjunction to specify a condition. Make sure to read all ICD-9-CM notes given.
Hypertension complicates a pregnancy. Is the hypertension pre-existing, what manifestations are present, and are they superimposed to other problems? Does the patient have edema or an abnormal lab result? Hypertension in a pregnant patient may:
- require anti-hypertensives,
- result in additional prenatal visits to monitor maternal blood pressure (BP),
- require antenatal testing to verify well-being of the fetus (NST, BPP, fetal echo),
- provoke testing for decreased fetal movement, oligohydramnios, and pre-eclampsiac,
- and put additional stress on the placenta.
Use ICD-9-CM codes 642.0X–642.9X for hypertension. When referring to this series of ICD-9-CM codes you may need clarification on these medical terms:
Pre-eclampsia is borderline hypertension, albuminuria, and unresponsive edema between 20 weeks gestation and first week post partum. With pre-eclampsia there is an excess weight gain of two plus pounds in one week and may have excessive swelling of hands, feet, and face. BP of pre-eclampsia is greater than 140/90. Look for albuminuria and elevated creatinine on 24-hour urine. The timing of delivery is critical.
Eclampsia is very much the same as pre-eclampsia/toxemia but can be accompanied by convulsions, coma, and edema.
HELLP syndrome is severe pre-eclampsia with severe hypertension, hemolytic anemia, elevated liver function tests, and low platelet count. The treatment is delivery.
644 Early Labor
Turn to ICD-9-CM’s 644 series for labor between the gestational age of 22-37 weeks, and turn to 640 series for labor prior to gestational age of 22 weeks. Codes 644.0X Early or threatened labor; threatened premature labor, premature labor after 22 weeks, but before 37 completed weeks of gestation without delivery and 644.1X Early or threatened labor; other threatened labor specify without delivery. Code 644.21 Early or threatened labor; Early onset of delivery is used for delivery before 37 weeks. Result of early delivery could be hospitalization requiring hydration, tocolysis, bed rest, monitoring of contractions, and home monitoring.
646 Other Complications NEC
Many complications or illnesses are spelled out in the ICD-9-CM 646 code series as not elsewhere classified (NEC). Use the appropriate code; use additional codes to further specify complication.
Example: If a patient has pyelonephritis in pregnancy, code 646.63 Other complications of pregnancy, not elsewhere classified; Infections of genitourinary tract in pregnancy; antepartum condition or complication and 590.1X Infections of kidney; Acute pyelonephritis.