Ob-Gyn Coding Alert

An increasing number of payers are refusing to reimburse the services of an assistant at cesarean delivery, says Melanie Witt, RN, CPC, MA, and former Program Manager, Department of Coding and Nomenclature, American College of Obstetricians and Gynecologists (ACOG). This is an inappropriate coverage and payment policy that should be challenged each time, for several reasons, she adds.

There are three major arguments for the reimbursement of the assistants fee:

1. A cesarean delivery represents major abdominal surgery. Most payers, including Medicare, CHAMPUS and Medicaid allow an assistant surgeon for major abdominal procedures and payment rules should be consistently applied.

2. Cesarean delivery involves the lives of two or more patientsmother and fetus(es). An assistant at cesarean is qualified to manage complications that may arise in both the mother and the fetus, thus facilitating a good outcome in the event of problems.

3. Because the uterus is an extremely vascular organ, rapid blood loss is always a potential problem during cesarean delivery. Without an assistant at cesarean, the outcome when complications occur can have dire consequences for the mother and the fetus.

Another issue with an assistant at cesarean delivery is coding for the service, The general CPT rule for coding an assistant at surgery, says Witt, is to add a modifier -80 (assistant surgeon) or -82 (assistant surgeon [when qualified resident surgeon not available]) if there is no qualified resident in a teaching facility situation, to the surgical procedure code, 59510 (routine obstetric care including antepartum care, cesarean delivery and postpartum care), reported by the primary surgeon. The payer reimburses a percentage of the allowable for the modified code because the assistant provides a lesser service and does not provide any postoperative services (which are included in the allowable for the procedure).

Witt argues that the cesarean delivery codes should be the exception to this rule because the global period is nine months long and the global code normally reported by the delivering obstetrician includes other services not provided by the assistant, such as prenatal care. In this case, the assistant should report the cesarean delivery only code (i.e, 59514 [cesarean delivery only] or 59620 [cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery]) with the appropriate surgical assistant modifier because assistance was not rendered over the course of the entire global period.

If the payer does not search for code matches between the primary and assistant surgeons, says Witt, this coding approach will not complicate payment for the service. If the payer does look for exact matches, additional documentation may be required or the insurer may initially deny one of the claims. To avoid payment delays, it is always a good idea to find out in advance how the insurer would like the service billed.