EM Coding Alert

If your ob-gyn provides antepartum care but did not participate in the delivery, then the go-to global codes 59400, 59510, 59610, and 59618 (Routine obstetric care including antepartum care ...) may not be appropriate.

Option 1: Look to E/M Codes for 1 to 3 Visits

“If the patient had a total of one to three antepartum visits, report the appropriate level of E/M service for each visit with the date of service that the visit occurred and the diagnosis for why the patient was seen,” states the American Congress of Obstetricians and Gynecologists (ACOG).

Example: If the doctor sees an ob patient twice before she transfers out of the practice, you will report the appropriate E/M code (99202-99215) for each visit with Z34.0- (Encounter for supervision of normal first pregnancy…) or Z34.8- (Encounter for supervision of other normal pregnancy …).

Option 2: Report 59425 for 4 to 6 Visits

On the other hand, if the ob-gyn sees the patient four to six times before she leaves that practice’s care, you will report 59425 (Antepartum care only; 4-6 visits), ACOG states. Because 59425 represents the total work involved with all of the visits, you should submit it only once with a “1” in the units box of the CMS-1500 claim form.

Best bet: Be sure to include the “to” and “from” dates during which the services occurred.

Enter the date of the first prenatal visit in box 15, and enter only the date of the last visit the patient was seen for prenatal care in box 25a, experts say.

Option 3: Consult Payers for Reporting 7+ Visits

If your physician provides seven or more antepartum visits, you should report 59426 (... 7 or more visits), according to ACOG.

As with 59425, you should report 59426 only once and place a “1” in the units box. You should also record the “to” and “from” dates for the services your ob-gyn provided.

Tip: To avoid reimbursement hassles, be sure to ask your payers how they want multiple antepartum visits coded. Each payer may have different requirements for reporting services — especially those services that vary from the usual — and physicians must know how to correctly report the services they provide to be compliant, as well as receive appropriate reimbursement for their work.

Note: Some payers may allow you to bill an E/M service instead of the antepartum visit package codes. And reporting individual visits allows you to get paid at the time of service rather than waiting until you complete the required number of visits and billing the corresponding code. And some payers may allow you to bill globally with a modifier 52 (Reduced services) attached when all the care is provided except delivery due to a home delivery, or vaginal delivery before the physician can make it to the hospital. This varies from payer to payer, so be sure to ask what their policy is, says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.