Ob-Gyn Coding Alert

With the HHS Office of Inspector General scrutinizing "incident-to" billing, ob-gyn practices must comply with strict guidelines to ensure proper reimbursement from Medicare for services provided by their certified nurse-midwives (CNMs). Otherwise, they could face exorbitant fines, penalties and repayments.

Many ob-gyn practices have enhanced their services by using CNMs to deliver care for ob patients, says Karen S. Fennell, RN, MS, a senior policy analyst for the American College of Nurse-Midwives. The CNMs may also provide Medicare-reimbursable services to the elderly and patients with disabilities. Specifically, Medicare pays for roughly 50,000 births for women with disabilities each year, Fennell says.

According to Medicare, incident-to services or supplies are those furnished as an integral, although incidental, part of the physician's personal, professional services in the course of a diagnosis or treatment of an injury or illness.

"Typically, however, the patient delivering the baby will most likely have insurance coverage other than Medicare," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm based in Lansdale, Pa. "Other payers may not recognize CNMs as direct billers. It is very important that ob-gyn offices check with their local third-party payers to determine their respective billing guidelines concerning CNMs, particularly when incident-to does not apply."

You should report CNM incident-to services under the ob-gyn's personal identification number (PIN) on the CMS 1500 form as if the physician performed them. Medicare carriers will reimburse these services at 100 percent of the Physician Fee Schedule. Alternatively, CNMs may bill services that fall within their scope of practice as defined by state law directly under their own name and PIN. Medicare pays covered CNM services at the lower of the actual charge or 65 percent of the fee schedule for a participating physician, Falbo says. "Payment for these services is made only under assignment," she adds.

Medicare provides four guidelines to determine if a service or procedure is incident-to. If the service does not meet these requirements, you should report it under the CNM's PIN.

1. Incident-to services must be an integral, although incidental, part of the physician's professional services. This means that the ob-gyn must be involved with the patient's care, Fennell says. The physician must see the patient first to establish a course of treatment. He or she can then delegate subsequent care and services, which can be billed incident-to. The doctor must also initially treat established patients who present with a new problem or condition.

Ob-gyn practices may often find that they have slipped away from this standard. Ob-gyns and CNMs may slide into a more casual approach, especially with established patients. This can lead to the CNM seeing patients without the physician being involved. Clearly, this does not comply with Medicare guidelines, and you should report such services under the CNM's PIN.

You should also keep in mind that the services and supplies reported incident-to must be those typically furnished under the doctor's PIN.

2. Incident-to services may be provided only in the physician's office, patient's home or an institutional office setting but never for hospital care. Some practices may believe they can report a CNM's services wherever he or she follows the ob-gyn. For example, a CNM may accompany the doctor to the hospital where the physician delegates rounds to the CNM and reviews the patients' records afterward. You cannot report this as incident-to.

The term "institutional office setting" describes a location where a physician leases a portion of another institution such as a room in a hospital as temporary office space. When a CNM provides care in such a space, you may report it as incident-to. If the midwife sees hospital patients in their rooms, however, you must bill these services under the CNM's PIN.

3. The physician must be "involved" when a CNM delivers care. This does not mean that the ob-gyn must be in the examining room with the CNM while he or she is providing care. Instead, the physician must be physically present within the office/building.

Some doctors may have offices that connect with a hospital. They may simply walk through a door or hallway to get from one to the other. But if the ob-gyn crosses that boundary into the hospital, he or she can no longer be involved with the patient's care, according to Medicare. Similarly, a physician's availability by phone does not provide sufficient involvement.

4. The ob-gyn and CNM must work in collaboration to bill incident-to. According to the Code of Federal Regulations, a collaboration is a process in which the CNM "has a relationship with one or more physicians to deliver healthcare services" (42 CFR 410.75). The CNM must document his or her scope of practice and indicate the relationship that he or she has with the physicians.

The following examples should help clarify any resulting confusion created by the Medicare guidelines:

Example 1: A full-time CNM is seeing patients in the practice when the gynecologist involved with the patient's care is called away to the hospital. During the physician's absence, the CNM performs a follow-up examination with a woman who had undergone a minor procedure a week earlier.

Coding Solution: You should report this visit directly under the CNM's PIN with the appropriate established patient E/M code (99211-99215), unless the service falls within a global surgical period. You cannot bill the CNM's services incident-to because the physician involved in the patient's care is not present in the office when the visit occurs.

Example 2: An established postmenopausal patient presents for a routine examination, and the practice's CNM performs a transvaginal ultrasound before the patient sees the ob-gyn. During the ultrasound, the physician is seeing another patient in the office.

Coding Solution: In this case, you can report the transvaginal ultrasound (76830, Ultrasound, transvaginal) incident-to because the physician has seen the patient previously. In addition, the CNM provides the services in space the physician owns or leases, and the doctor is on-site to confer with the midwife.

Example 3: The practice's CNM monitors a patient's labor in the hospital for several hours before the delivery terminates in an unplanned cesarean section performed by the obstetrician.

Coding Solution: You should assign the appropriate initial E/M hospital care code (99221-99223) to describe the CNM's initial hospital care, Falbo says. You could also report +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill patient]; first hour [list separately in addition to code for inpatient evaluation and management service]) for the first hour of labor management the CNM performs beyond that described in the initial hospital care code. You should report each additional half-hour of care with +99357 ( each additional 30 minutes [list separately in addition to code for prolonged physician service]). You cannot report this service as incident-to because it takes place in the hospital.