Like many pregnancies with complications, the first step is to determine what evaluation and management (E/M) care is included in the global ob package, and what is considered above and beyond and therefore billable as separate from global. Each insurance provider generally establishes a certain number of visits that are considered part of the global package, usually around 12 or 13. Additional antepartum visits beyond 13, when backed up with the proper documentation, should be billable outside of the global ob fee.
More Babies Mean More Complicating Factors
Philip Eskew, MD, medical director of the women and childrens services at St. Vincent Hospital in Indianapolis, outlines some of the complications with grand multiparity. Any multiple pregnancy, says Eskew, is automatically considered a high-risk pregnancy. There are several more prenatal visits and a great deal more monitoring of the pregnancy that has to take place. Not only are you paying special attention to the mothers health but to the growth rate and health of all the babies. Typically, that extra care can involve such procedures as fetal non-stress tests (NSTs) (59025, fetal non-stress test), biophysical profiles (76818, fetal biophysical profile), and several ultrasounds to monitor the growth of each baby. Eskew also says that with multiparities, the blood pressure levels of both mother and fetuses require extra monitoring.
The main thing to remember with multiple gestations, says Eskew, is the numerous times that you have to see the patient. There are so many factors to considerand thats true even with a twin pregnancywhen you start talking about three or four babies, the workload increases exponentially.
Diana Barnes, a coder for Laurel Ob/Gyn Associates, a multi-physician practice in Charlotte, N.C., recalls a case of triplets delivered recently. We only saw the patient 15 times, says Barnes, which really isnt that far outside of the number of visits allowable in global. But we performed four ultrasounds, which is a little unusual, but she had some bleeding early on. Barnes continues, Her records also indicate that we did several injections of Celestone Soluspan (an intramuscular [IM] injection, HCPCS code J0702 or J0704) to prevent respiratory problems in the fetuses. We billed all of these items separately from the global care.
When conducting ultrasounds on more than one fetus, remember that you also are dealing with more than one patient, hence the procedures can be coded separately. Melanie Witt, RN, CPC, MA, former program manager of the department of coding and nomenclature at the American College of Obstetricians and Gynecologists, explains. If the ultrasounds are conducted to monitor fetal position and growth76810 (echography, pregnant uterus, B-scan and/or real time with image documentation; complete [complete fetal and maternal evaluation], multiple gestation, after the first trimester) or 76815 (echography, pregnant uterus, B-scan and/or real time with image documentation; limited [fetal size, heart beat, placental location, fetal position or emergency in the delivery room])this takes more work and is billable as three separate procedures. Each ultrasound can be coded separately using modifier -51 (multiple procedures), or a quantity of three can be used if the code is listed once. Witt points out that these are billable separately only if they are documented three individual times (in the case of triplets). Think of each fetus as a separate patient, and document accordingly, says Witt.
Coding and medical experts agree that the best way to prepare your insurance company for the onslaught of extra claims associated with multiparity is to make sure from the outset that they know how many babies you are dealing with. Insurance companies tend to look at triplets in a different light than twins, says Witt. Twins are considered much more routine. But triplets (or more) are another story. You may actually have an easier time getting reimbursed for your additional efforts when dealing with three or more babies.
Some Extra Work at Delivery Is Reimbursable
Coding for the extra tests and E/M visits necessary for a grand multiparity is pretty straightforwardgood documentation will bolster your claim for the extra work. But things get a little more complicated when it comes to delivering all those babies.
This is not going to be an easy delivery, says Eskew of any grand multiparity. There is more operating room time to coordinate, extra personnel to receive the babies as they are delivered, increased chances of bleeding problems from the mothers enlarged uterusplus the fact that you are almost certainly looking at a cesarean delivery.
Eskew outlines two coding methods, assuming no other complications and no specialist is called in to help with the delivery. You could code the delivery as you would any multiple gestation, says Eskew, using the global ob code for a cesarean delivery, 59510 (routine obstetric care including antepartum care, cesarean delivery and postpartum care). Then code each additional fetus as delivery-only with a reduced service modifier59514-52 (cesarean delivery only; reduced services).
Eskew says that most insurers will look at this scenario and pay 100 percent of the global amount on the first baby, 50 percent of the delivery charge on the second, 25 percent on the third and 0 percent on the fourth or more. Given these reimbursement ratios, Eskew says, You might be better off to call the insurer first and ask them how they want you to submit this claim.
Eskew says the alternative to the above coding sequence is to submit code 59510 with a -22 modifier (unusual procedural services), along with a letter documenting the extra work involved. Witt feels that this is the best approach to multiparity delivery. With a surgery like a c-section, many payers only pay per incision, says Witt. Therefore, most insurers will accept your global with a c-section but are likely to reject the additional delivery only codes because all the deliveries came from the same incision. Both Witt and Eskew agree that regardless of how you handle billing of the delivery, the additional office visits should be billed outside of global.
Majority Rules When Billing for Global
Witt raised the possibility that the patients obstetrician would send the patient to a maternal fetal medicine specialist (MFM) for consultation and possible monitoring of the pregnancy. If the MFM takes over the monitoring of the pregnancy, then a new set of problems arises: Two doctors are billing for ob care. Neither doctor will be able to bill for global care, unless the insurer insists on it. One of the doctors will bill for the delivery, which again almost inevitably will be a cesarean. If both doctors are present for the delivery, one would bill as the primary surgeon, 59514, the other would bill for an assistant surgeons fee, 59514-80 (cesarean delivery; assistant surgeon).
When an ob and a specialist both see the patient, the insurance company may accept only itemized billing. Sometimes they will allow the primary ob to bill the global care with a modifier -52 (reduced services), but it is best to check with the payer before doing so. Correct coding may also depend on who will be doing the postpartum care because your choice of code when itemizing will either be cesarean delivery only or cesarean delivery with postpartum care.
The way this is coded will depend on whos doing what, says Witt. Grand multiparity is a perfectly codable event. But the insurer may take this accurately coded case and start saying, Well pay for this but not for that, and thats when it gets difficult for a practice to get paid. All you can do from a billing standpoint is make sure that you are coding accurately, provide good documentation of the care, and hope the wrinkles work themselves out along the way.