Ob-Gyn Coding Alert

Editors Note: Last months case focused on the patient with multiple visits to address the problem of infertility. This month we focus on the problem of coding for pregnancy testing and office visits. To do so we continue the case of our 27-year-old patient who had been unable to conceive after more than one year of intercourse without contraception. She had been put on clompiphene citrate for six cycles, which was followed by menotropins therapy. She has now missed a menstrual period and returns to the reproductive endocrinologist to confirm pregnancy.

To recap, during our patients last visit to the reproductive endocrinologist on May 30, she had an ultrasound that confirmed that she was ready for her injection of hCG and this was administered at that visit. A progesterone blood test was done to confirm ovulation 24 hours after the hCG injection at the outpatient lab. At that point, the patient is instructed over the phone on when and how often to have sexual intercourse. She is instructed to call the office if she has a normal period, or to make an appointment for confirmation of pregnancy if her period has not started after June 21. Happily, our patient misses her period and comes in to confirm pregnancy. She sees the endocrinologist on June 15 where a pregnancy test is performed. On June 17 she comes in to learn that she is pregnant and to determine what will happen next. At this visit, she also has a repeat hCG drawn to correlate the results of the previous test. The physician calls the patient the next day to confirm pregnancy and tells her to make her first appointment with her obstetrician.

Coders Notebook

The patients first visit, after missing her period, on June 15, is to confirm pregnancy. This visit might be billed as a level 2 or 3 office encounter, depending on whether the visit was controlled by history/exam/medical decision-making or by counseling (that is, the level is selected by documented counseling time).

There are basically three choices for billing the pregnancy test or a part of it.

1. If the office sends the test out to an independent lab, but bills for the service on behalf of the lab, the office bills for the laboratory service by adding a modifier -90 (reference [outside] laboratory) to the lab code.

2. If your ob/gyn office has a laboratory qualified to perform the pregnancy test, no modifier -90 would be added to the lab code reported. In either of these two instances, however, a blood draw would probably not be reimbursed separately by the payer, because many carriers roll this part of the service into the allowable for the test.

3. If, however, the office draws the sample and sends this off to the lab that performs, interprets and bills for the test, the payer is likely to allow an additional amount for the blood draw.

The diagnosis at this visit will be her previous diagnosis of infertility (628.0) with a secondary diagnosis linked to the lab test or blood draw for a pregnancy test unconfirmed (V72.4).

The physician has the patient return in two days to discuss the lab results, which we find out confirms pregnancy, and to perform a second hCG to correlate the previous result. For this visit, the level of E/M service will probably be based solely on time, so there could be a level 4 (25 minutes) or level 5 (40 minutes) encounter. Once again, the lab code or blood draw could be billed. The diagnosis for this visit changes, however, because pregnancy has been confirmed. Now the ICD-9-CM code V23.0 is reported to indicate the supervision of a pregnancy with a history of infertility.

The next day, the physician calls the patient with the second test result and tells her to call her obstetrician to begin care. This call, if the physician chooses to bill for it, would be billed to the patient, not the payer. The diagnosis continues to be V23.0.

Since the reproductive endocrinologist has now essentially transferred care of the patient to the obstetrician, any additional visits to the endocrinologist might not be paid by the insurer. The endocrinologist would have to show the medical necessity of seeing the patient concurrently with the obstetrician. The same would apply to an
ob/gyn transferring care back to a family practice physician.

Article contributors: Expert advice for this case study was provided by the following sources: Melanie Witt, RN, CPC, MA, program manager, department of coding and nomenclature, American College of Obstetricians and Gynecologists, Washington, DC; Evelyn Gross, CMM, CPC, NR-CMA, Healthcare Specialist for Amper, Politziner & Mattia in Edison, NJ; Thomas Kent, CMM, principal, Kent Medical Management, Dunkirk, MD; Dunnihoo, DR Fundamentals of Gynecology and Obstetrics.

Editors Note: If you have a case you would like to submit for consideration, please send it via fax, email or mail.