Coding Maternal-Fetal Medicine
With understanding comes passion for this ob-gyn niche.
Obstetrics and gynecology (ob-gyn) coding is one of those specialties you either love or just don’t get. Or maybe you love it, but just don’t get it.
Peggy Stilley, CPC, CPMA, CPC-I, CPB, COBGC, worked in ob-gyn and maternal-fetal medicine (MFM) for 15 years before venturing into other areas. “Maternal-fetal medicine was my passion, and I loved the challenge of it,” she said.
Part of the challenge of working in an ob-gyn practice is knowing when the patient needs to go to MFM. Do they go just for antenatal testing? Do you have to transfer the patient? MFM doesn’t fit into the block for anything: It doesn’t have a 90-day global. It doesn’t have a zero global. And, thankfully, pregnancy isn’t a chronic problem (by Medicare’s definition, chronic conditions are those that are expected to last at least 12 months). You’re also dealing with two or more patients. To make matters even more challenging, payers don’t always follow CPT® guidelines.
At HEALTHCON 2021, Stilley removed a lot of animosity that coders in attendance may have held for the specialty in her session “Coding Maternal-Fetal Medicine.” Here’s a recap of that session.
What Is Maternal-Fetal Medicine?
MFM is the practice of caring for patients with complications of pregnancy. In essence, MFM is consultative. MFM specialists generally don’t always perform deliveries; but they might determine when it’s time for delivery.
The patient(s) may be the mother, the unborn infant(s), or both. Maternal-fetal medicine is a recognized sub-specialty of ob-gyn with its own taxonomy code (207VM0101X). This is important to know when credentialing your maternal-fetal medicine specialist because it can make a difference in reimbursement.
Global Care vs. Consultative Services
The obstetric package includes prenatal visits, delivery, and postpartum care. The CPT® codes for these services, depending on delivery method, include:
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery
These codes capture all visits, typically 13-15, but “don’t get hung up on your number of prenatal visits,” Stilley said. The number of visits will vary, depending on when the mother comes in for her initial visit, when she delivers, and the health status of the mother and baby(ies). Postpartum care generally lasts six weeks; although, some payers may allow eight weeks.
The following services are not included in the global package, per CPT® guidelines:
- Biophysical profile (BPP)
- Fetal non-stress test (NST)
- Hospital admissions
Exception: Some payers will bundle ultrasonography into the global package. When a provider always does something, it becomes a standard of care, Stilley explained. When a payer sees that a provider always performs a 16-week ultrasound, it can become that provider’s standard of care, giving the payer the green light for bundling the ultrasound into the global package.
Coding Fetal Ultrasounds
Ultrasound code selection is based on the gestational age, number of fetuses, and medical necessity. The physician or other qualified healthcare professional may perform an ultrasound on a patient in her first trimester to determine the number of sacs and to survey the fetal structures, amniotic fluid, and maternal structure. Coding for this service is:
76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation
+76802 each additional gestation (List separately in addition to code for primary procedure)
From a payer’s perspective, the provider must document the maternal anatomy. In Stilley’s experience, this information is often not documented. Documentation needs to be clear: If the provider wasn’t able to see the maternal structures, why not? By the way: Identifying the baby’s gender does not support medical necessity, Stilley warns. And “size/dates” is insufficient documentation to show medical necessity for an ultrasound.
First trimester screening is offered to determine the risk of certain chromosomal conditions. This screening entails:
- Focusing on the fetal neck
- Looking for chromosomal abnormalities
- Calculating fetal length and depth of tissue
- Blood testing
The code(s) for a first trimester screening are:
76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation
+76814 each additional gestation (List separately in addition to code for primary procedure)
The physician or other qualified healthcare professional may perform an ultrasound on a patient after her first trimester to evaluate the maternal and fetal structures. Coding for this ultrasound is:
76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation
+76810 each additional gestation (List separately in addition to code for primary procedure)
Documentation should include number of fetuses and amniotic/chorionic sacs and survey of intracranial/spinal abdominal anatomy, four-chambered heart, umbilical cord insertion site, placental location, amniotic fluid assessment, and exam of maternal adnexa, if visible. If the maternal adnexa are not visible, the provider should document why not — generally, because the baby has grown and is now blocking the view.
Typically, you will bill 76801 and/or 76805 only once because if the provider finds something that needs further evaluation, another comprehensive ultrasound isn’t necessary.
76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation
+76812 each additional gestation (List separately in addition to code for primary procedure)
CPT® 76811 includes the performance of all the components in 76805 plus a detailed fetal anatomic examination including brain/ventricles, face, heart outflow tracts, chest anatomy, abdominal organs, limbs, umbilical cord, placenta evaluation, and other fetal anatomy as indicated. Documentation should mention what the provider is looking for. What did the provider see on the 76805 that warranted the 76811? You can’t skip over the 76805 and go directly to the 76811 without documented medical necessity for the additional work, Stilley said.
In a transvaginal ultrasound, the provider is looking at the mother’s cervix for any concerns, such as “funneling,” which is protrusion of amniotic membranes into the internal cervical orifice.
76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal
Ultrasounds with different approaches may be performed and can be billed together. Follow-ups are billed using one of the following codes:
76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses
76816 Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus
As the descriptors state, you can bill 76815 only once per exam, whereas you can bill 76816 for each fetus. If an ultrasound is separately billable, it does not require modifier 51 Multiple procedures and it does not include pre- or post-op elements or time the provider spends discussing or reviewing the test results. These are separately billable services. Coding is dependent on the payer and patient (e.g., Does the payer allow for consultations? Is the patient new or established?).
BPPs are physiologic tests, not anatomic ultrasounds. A physician may conduct a BPP to look at fetal heart tones, amniotic fluid, and breathing, and may or may not conduct NST. The codes are:
76818 Fetal biophysical profile; with non-stress testing
76819 Fetal biophysical profile; without non-stress testing
Indications for these codes include maternal hypertension, diabetes mellitus, coagulation defects, and multiple gestations, to name a few.
Amniocentesis may be diagnostic or therapeutic. A diagnostic amnio may involve sending the fluid to a lab for genetic testing.
59000 Amniocentesis; diagnostic
76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation
Watch out! Although 59000 does not require prior authorization, sending the sample to the lab for genetic testing often does.
Therapeutic procedures are for high-risk patients and are not typical. Therapeutic codes are:
59001 Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance)
59070 Transabdominal amnioinfusion, including ultrasound guidance
59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance
59076 Fetal shunt placement, including ultrasound guidance
These codes include ultrasound guidance.
Two other invasive fetal procedures your MFM specialist might be doing are cordocentesis, or percutaneous umbilical cord blood sampling (PUBS), and transfusions.
59012 Cordocentesis (intrauterine), any method
36460 Transfusion, intrauterine, fetal
Cordocentesis is a diagnostic test used to determine whether there are any abnormalities present in the fetus. A blood sample is taken from the umbilical cord. This is typically done after 18 weeks for infections or anemia, and it can also detect genetic abnormalities. The 36460 is an infusion of fetal blood cells that is done for the baby and is typically done for Rh incompatibility. Report 76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation for guidance.
One of the basic guidelines that we learn early on is that Chapter 15 codes take priority over every other chapter in the book. “This is a problem because when you have a high-risk diabetic patient, the plan of care may include visits with other specialties,” stated Stilley. “What is the typical plan of care for that patient? They’re going to go to the ophthalmologist. They’re going to see the cardiologist. They may have their hearing checked. They may need to see a nephrologist for kidney evaluation. What is the diagnostic code that the specialists typically are putting on the claim form? Often codes from every other chapter except Chapter 15 are reported because those are the codes used by their specialty, but it’s not correct.”
“Coders who work in nephrology, cardiology, and other specialties should be aware that they need to be sequencing Chapter 15 codes first,” Stilley said.
There is a code for every most all situations in the ob-gyn chapter, and those are the correct codes to be reported. The problem is, when a mom who is admitted to the hospital for a condition and she is pregnant, the number of days allowed or approved may be limited based on pregnancy and not on the complicating condition. It’s the physician’s responsibility to state whether the condition being reported is a complication of pregnancy.
What is a high-risk pregnancy (Category O09)? The definition is open to the provider’s interpretation. “Talk to your physicians about what they consider high risk,” Stilley advised.
Common maternal conditions include:
- Diabetes in pregnancy (O24)
- Hypertension (O10-O15)
- Coagulation defects (O99.1)
- Epilepsy (O99.35)
Common fetal conditions include:
- Multiple gestation (O30)
- Size discrepancies (O36.5x-O36.6x)
- Isoimmunizations (O36.0)
- Anemia (O36.82)
- Abnormal heart rate (O36.83)
- Malposition (O36)
Remember the outcome code (Z37). For high-risk patients, you may want to append a modifier 22 Increased procedural services to the code(s). “But you’re going to have to justify that,” warned Stilley. “… and you’re going to send your claim into automatic review.”
Ultrasounds are also used to confirm the anatomy of multiples as shown in the illustration above. You may see terms such as Di/Di, Mono/Di, and Mono/Mono, which will lead you to the diagnosis codes. It helps if you understand the different types of anatomy multiples may have in the womb.
When coding maternal-fetal medicine, remember:
- A transvaginal ultrasound can be billed with a transabdominal ultrasound.
- The professional component (modifier 26) can be billed for services at the hospital.
- Check payer policy for the use of modifier 59 on BPP for multiple gestations. Some payers prefer 76818 x 3, others prefer 76818, 76818-59, 76818-59.
- Ultrasound add-on codes do not require modifier 51 or 59.
- Use modifier 59 for NST or multiple gestations.
Love Ob-Gyn Coding? Earn Your COBGC™
Attendees left this session with a better understanding (or maybe rekindled love) of MFM coding. I wouldn’t be surprised to see an uptick in Certified Obstetrics Gynecology Coders (COBGC™) in the near future! Register for HEALTHCON 2022, March 27-30, in Washington, D.C., to attend presentations such as this one, live or virtual, and earn continuing education units (CEUs) while learning, networking, and having an all-around great time!
Speaking of CEUs, take the online Test Yourself quiz this month to earn one CEU. Hint: The answers to two of the questions can be found in this article!
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