Ob-Gyn Coding Alert

Perinatologists or maternal fetal medicine (MFM) specialists often are called in on a one-time-only basis for consultation with a high-risk ob, or when the patients primary ob/gyn has suspicions or concerns of a complication in the pregnancy. The perinatologist typically may perform a level-four consultation with the patient (99244, office consultation for a new or established patient, requiring a comprehensive history, comprehensive examination, and medical decision-making of moderate complexity) and frequently runs additional tests. Yet getting paid for those visits as consultations remains a challenge for many of these specialists.

Problems Convincing the Carrier

Cheryl Christy, billing coordinator at University Perinatal Consultants, works with seven perinatology professors and assistant professors at Ohio State University in Columbus. The physicians also have a private practice and provide high-risk coverage for every hospital in Columbus. Christy typically has several doctors at different hospitals every day, where they all cover labor and delivery.

When asked about problems with reimbursement, Christy recounts difficulties, including a recent newsletter article from an insurance company. An article in a provider newsletter from one of our major carriers said they would automatically deny every consult submitted and downcode it to an evaluation and management (E/M) service for a new patient. The article explained that because the providers were billing so many consultations incorrectly, they were going to downcode across the board. The same article said that even if we submitted a hard copy of the referral and attached documentation of the work that was done and the letter from our doctor back to the PCP (primary care physician) all steps that would prove a consultation the consult would be denied. We would have to go through the appeals process to get paid for the work we did, she adds.

Other carriers also only pay for a regular E/M visit, which reimburses at a lower rate than a consultation. Even when weve gotten the consult precertified, the claim gets denied, Christy says. Part of the denial problem may be the insurance companies computer software programs. Christy explains that the software does not read the box on the HCFA 1500 form that lists the referring physician. Therefore, the computer reads the visit as a regular E/M for a new patient, rather than as a consultation. In the best-case scenario, a phone call to the carrier gets the reimbursement ball rolling, but often there is a lengthy appeals process for denied claims.

Doris Queen, RN, clinical nurse for Oscar Mims, MD, FACOG, a solo-practice perinatologist in Washington, D.C., handles billing and coding as well. She shares the frustrations with getting paid for consultations. Insurance companies are not interested in hearing that Dr. Mims is a perinatologist, says Queen. They [...]