Ob-Gyn Coding Alert

Case Study:

Correct Coding of Additional E/M Visits Maximizes Payment

Ob/gyn coders can increase reimbursement and reduce denials by correctly assigning evaluation and management (E/M) codes for visits above the normal number that are considered part of the global ob care.

Specific scenarios were raised by Patricia Marth, practice manager of College Heights Ob/Gyn Associates, a six-physician, one-nurse practitioner ob/gyn practice that is part of a large, multi-specialty physician group in Allentown, Pa. About 7.5 percent of all College Heights ob patients are high risk.

Marths first example is of a high-risk patient at risk for gestational diabetes and pregnancy-induced hypertension. The patient has had at least six to eight more prenatal office visits than a routine ob, says Marth. Should we add dollars and support that addition with medical records, or should we append our claim with additional E/M codes to account for the extra services? And what, if any, modifiers would be used in this scenario?

Code Extra Visits in One of Two Ways

Typically, the normal global ob package consists of about 13 visits (within a range of 10 to 15). Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature, says that it is acceptable to bill for additional antepartum care dealing with complications of pregnancy in one of two ways. As you suggest, Witt says, you can add modifier -22 (unusual procedural services) to the global ob code and send in documentation in support of the additional visits.

The other alternative, according to Witt, is to itemize each visit beyond the 13th one by reporting an E/M code level that is supported by the documentation in the antepartum record. There are no appropriate modifiers for this situation, says Witt, so just bill the E/M services, making sure you have proper documentation.

Of the two alternatives, itemization or use of the -22 modifier, Witt prefers itemization. Itemization preserves data about the visit, says Witt, but either method may work. There is no need for modifiers when you itemize the visits, as each is a stand-alone service for a complication of pregnancy.

Although the use of itemized visits is most preferable, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., it would be useful to contact the insurance carriers you deal with most often and ask them which way they prefer. That way, you reduce the instances of delay caused by using a method of billing that is not recognized by the carrier.

Witt says that if the payer denies the additional antepartum visits on the first submission, appeal the decision and be prepared to support the request with additional information. Just make sure your diagnoses support the reason for the visit; i.e., do not use V22.0 (supervision of normal first pregnancy) or V22.1 (supervision of other normal pregnancy) as justification because all these say is that you are supervising a normal pregnancy.

Inpatient or Outpatient Observation?

Marth also asked for assistance with the following three scenarios: We have had each of these situations present themselves recently, says Marth, and are uncertain how to differentiate:

One ob patient presented at the hospital for a problem and was observed for less than 23 hours.

Another ob patient presented to the hospital during off-hours (Sunday) for an ob check and was discharged.

A third ob patient had a level-three E/M hospital visit but was not admitted.

These circumstances are similar enough to cause confusion about when to use what code.

When dealing with observation care, Witt reminds readers, A patient is not an inpatient unless admitted to the hospital by the physician. This means that you could never bill an inpatient care CPT code unless the patient had been admitted. That leaves two other types of potential servicesobservation service or outpatient service. An observation service (99218-99220, initial observation care, new or established patient), says Witt, is billed when the physician has admitted the patient to observation status and has documented all three key components (detailed or comprehensive history; detailed or comprehensive examination; medical decision-making of straightforward, moderate or high complexity). This means that the physician must physically see the patient. Monitoring the patient or managing the care over the phone does not qualify as observation care.

Witt says that although CPT has not developed typical times for observation care as it has with other E/M care categories, it is generally assumed that the patient is being observed over a longer period of time. (Medicare stipulates more than 12 hours, says Witt.) So if the patient were observed for only one hour, the outpatient E/M codes (99211-99215, office or other outpatient services; established patient) would be more appropriate.

"Using Marths examples, says Witt, in the first scenario, the patient with a problem being observed for less than 24 hours would qualify for observation care. The second scenario, which involves an after-hours ob check,
Would be better billed as an outpatient E/M service, says Witt. She adds that if the patient is term and no problem is found, some payers may deny the E/M service.

In the third scenario, says Witt, (a level-three inpatient service was provided but the patient was not admitted), the correct code would be for an outpatient E/M service, established patient level-four visit (with detailed history; detailed examination; and medical decision-making of moderate complexity). This level corresponds most closely to the services that would be provided for a level-three inpatient visit.

Whenever possible, coding experts recommend negotiating in advance with your patients insurer for the compensation of visits outside the global period. For patients with a history of difficult pregnancies, hypertension, diabetes or other complicating factors, contact the insurance company as early as possible in the pregnancy and establish an understating of what will and wont be covered outside of the maternity global package.

In the event that complications dont arise until later in the pregnancy, keep careful documentation of all the requisite global and additional E/M visitsto ensure as smooth a claims process as possible and to be ready if an appeal is required.

For additional information on this topic, see How to Negotiate in Advance for High-risk Ob Patient on page 9 of the February 2000 Ob-Gyn Coding Alert.