Ob-Gyn Coding Alert

One of the most frustrating aspects of obstetrical care is reimbursement for the global service. Rules and reimbursement rates vary among payers, especially when there are complications or other issues in the pregnancy that make it nonroutine. By defining in writing what your practice considers standard global ob care and getting payers to accept that definition, you can head off reimbursement problems.
 
An amendment to a payer contract defines the realm of global ob package and ensures maximum reimburse-ment. A typical amendment covers the services normally included in global care, the services not included as part of global care and how the pregnancy management is coded when a global code is not employed, e.g., antepartum visits, delivery charges (vaginal or C-section), postpartum care and complications.
 
Helene Stout, director of business services for Fort Collins Women's Clinic, a comprehensive women's health facility in Fort Collins, Colo., has developed an amend-ment that almost all of the practice's major payers have accepted as a part of their contracts with the clinic. "Our practices are driven by submitting the codes that best describe the services we have rendered and not to bundle and unbundle at will," Stout says. "Yet insurance com-panies seem not to be driven by those same rules and can adopt their own interpretations of coding rules." This was Stout's impetus for developing the amendment and fight-ing to have payers accept it.

 
Stout says that getting payers to agree to the practice's amendment "wasn't as hard as you may think." By using established criteria to develop her document, she had official "backup" if a payer challenged its contents. "The amendment closely follows CPT guidelines," Stout says, "so we are really not making up our own rules." Stout also consulted with ACOG for coding recommendations for multiple births. "Having these two organizations support the billing concept helps immensely." She feels that setting a very strict guideline for the payer is easier for them because it leaves very little to the discretion of the claims reviewer. All the parameters are easily programmed into the payers' computerized claims programs. "Most payers will sign the agreement," she says, "and for those with whom I have a history of difficulty, I simply mail a copy of the amendment with the claim."
 
Some payers still resist when asked to pay for E/M visits unrelated to the pregnancy, but documentation can solve that problem. "We require our doctors to dictate a complete E/M note when they provide and charge for this service," Stout says, "so that makes appealing a denial a little bit easier."

 
While Stout's amendment (see box on page 69) outlines the basics of uncomplicated care, it may not go far enough, especially when determining what is excluded from the global package. CPT outlines several items that are coded separately from the global ob code that practices should consider including in any contract amendment:
 

Charges for the initial testing for an unconfirmed pregnancy (84702-84703 or 81025 and E/M visit);
 

Fetal biophysical profile (76818-76819);
 

Fetal echocardiography (76827-76828);
 

Amniocentesis (59000);
 

Cordocentesis (59012);
 

Fetal non-stress test (59025);
 

Observation care for premature labor prior to 36 weeks gestation (hospital visits within 24 hours of delivery are considered part of the global package);
 

Services for problems unrelated to pregnancy, but complicating pregnancy, such as hypertension, maternal diabetes, etc.
 
In addition to CPT's guidelines, practices -- especially those that treat many high-risk obs -- should include those services related to complicated or high-risk pregnancies in their "excluded" list. The distinction between "high risk" and "complicated" may be a sticking point for some carriers.
 
Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., explains that the term "high risk" implies that due to previous histories of pregnancies or current health concerns, the physician believes the patient must be monitored more closely, the result being more office visits and additional tests. "Complicated" means there are issues related to the pregnancy or the patient's health that are affecting her ability to carry a child to term or deliver a healthy baby. Such conditions include gestational diabetes, pre-eclampsia, hyperemesis, antepartum bleeding, premature rupture of membranes, fetal distress and infections.
 
"These conditions will definitely require additional monitoring and office visits, but the extent of the extra work will not be known until the conclusion of the pregnancy," Callaway says. "Plus, payers are more likely to pay for extra charges due to complications than they are to pay for the suspicion of complications." For that reason, practices that draw up a contract amendment should cast a wide net and include virtually every additional charge that could be encountered with the high-risk patient.
 
The amendment should articulate policies on hospitalization, either as inpatient or observation status, epidurals, external cephalic version and any other services that might be required for the high-risk or complicated pregnancy. Callaway recommends that even when amendments include this information, practices should contact the carrier as soon as they learn the patient's high-risk or complicated status and alert them that this will not be a normal global coding and reimbursement case.
 
Stout says the point of a contract amendment is that payment guidelines are clearly stated by both CPT and ACOG and are not some fabrication of a provider or payer of what to charge and what not to charge. "An amendment keeps us from saying, 'It's up to the policies of the payer,' and ensures that the payer follows the already-established, nationally published rules of coding and reimbursement for obstetric services," she says.