Ob-Gyn Coding Alert

How to Negotiate in Advance for High-risk Ob Patient

To improve chances of receiving appropriate reimbursement when treating a high-risk ob-gyn patient, contact the specific payer as soon as possible. Explain the special conditions and the additional services that may be required to provide proper care to the patient.

We recently received a letter from a perinatology practice at St. Johns Mercy Medical Center in St. Louis. Chris Gazall, office coordinator for the practice, writes that the office consistently has problems getting reimbursed for high-risk obstetrics (ob) care. All the patients we see are high risk, Gazall writes. Most of them have diabetes, hypertension, preterm labor, twins, triplets, etc.

Gazall explains that they have been turning in their claims with full op notes, and billing for global care with a -22 modifier (unusual procedural service) and diagnostic code V23.89 (other high risk pregnancy). Still, writes Gazall, We never get paid anything but regular ob rates. Regardless of how much documentation the practice submits they are only being reimbursed for regular ob care. We then have to appeal every delivery, writes Gazall, and most of the time we lose the first appeal. If the doctor writes a letter to the insurer, it takes months to get a response, and that response is usually not in our favor. Understandably, Gazall feels that the practice should be getting paid for these difficult cases.

She also asks if the practice should be billing the office visits that pertain to the high risk separately (such as 99212-99215, E/M visits for established patients), exclusive of antepartum care, then billing for delivery and postpartum care.

We asked Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., for her input into Gazalls plight. For starters, she says that Gazall cannot bill office visits separately from the antepartum visits included in the global package until the office visits exceed the normal number of visitstypically 12 or so. Once this number of visits is reached, Gazall can bill for the additional office visits using the E/M codes.

Planning Ahead Avoids Problems

According to Callaway-Stradley and other coding experts we asked, the crux of the problem is that the practice is not negotiating in advance with their insurers. Particularly for high risk ob, says Callaway-Stradley, you want your carriers to know in advance what kind of problems you may encounter, and determine with them what they are willing to pay for. This leaves room for fewer surprises and denied claims in the end.

Curt Udell, CPAR, CPC, president of Emphysys Inc., a physician reimbursement and consulting firm based in Cumming, Ga., says that while there are always potential problems with reimbursement for any high risk service, there are steps to take to circumvent those problems.

With reimbursement, says Udell, everything is based on benefits. Within every insurance contract, there is some definition of what is covered and what is not, as well as what special conditions are covered. Obviously, it is important for billing or office managers to be familiar with all their different carriers contracts. But lack of familiarity may not always be the problem. Udell explains, It could be that the insurer does not have adequate definitions of what conditions are covered. This can be true whether you are dealing with perinatology or standard ob/gyn.

Udell recommends that office staff contact the insurer as soon as they have the patients insurance information. When a patient gives you her insurance card, collecting and entering the data is only half the job. Practices need to contact the insurance company immediately, explain the patients medical condition and what levels of treatment or E/M management are likely to be required and see if there are any issues.

In an ideal case, says Udell, there is a lag between the patients initial visit and their next appointmentthe beginning of their global treatment period. This is the time during which staff should work with the insurer to determine what is covered and what is not. Udell continues, This is particularly important in high risk ob where additional services are often required. Remember that the person adjudicating the claim at the insurance company is probably not very clear as to what these additional services are.

When using the -22 modifier, Udell cautions that practices really need to produce a great deal of documentation to justify its use. The -22 modifier indicates that the practice is giving 120 percent of what is typically provided with the global package, says Udell. It is a red flag to many insurance companies and often gets kicked out if there is the slightest question. Provide heavy documentation and contact the specific payer to let them know in advance what service is being provided.

Ultimately, Udell says, it is still up to the insurance company to decide how theyre going to process the claim, and what theyre going to pay for. He says that, unfortunately, maternity care is becoming an increasingly more difficult coverage area. My clients are telling me that as insurance rates are going up in general, maternity rates are skyrocketing, says Udell. Still, I am inclined to believe that if you show people the amount of work youre doing, they (the insurance companies) will understand that its above the norm. Focus on the top five or 10 companies that you have to work with, and try to meet them halfway.

In a case like Gazalls, Udell recommends developing a list that details standard ob care vs. perinatal or high risk ob care. In the right hand column, show standard care, and in the left show high risk care. Prove to them that it doesnt make sense that you be reimbursed the same lesser amount for both, says Udell.

Note: For more information on appeals, negotiating with insurers and high-risk ob, consult Successful Appeals of Ob/Gyn Claim Denials on page 91 of the December 1999 Ob-Gyn Coding Alert and Overcoming the Reimbursement Challenges of the Diabetic Ob Patient on page 1 of the January 2000 Ob-Gyn Coding Alert.