Eileen Bradley is a coder who specializes in ob/gyn surgery billing for Brighams Surgical Group in Chestnut Hill, Mass. The group does the billing for the Brigham and Womens Hospital in neighboring Boston. She recounts a recent case when multiple births occurred on separate days. Twin one was delivered vaginally by vacuum extraction on Feb. 8, and twin two was delivered by cesarean section for failure to descend on Feb. 9. Bradley explains that there was a time lapse of at least six or seven hours between deliveries.
Second Delivery Is Billable Separately From Global
Under a normal multiple-gestation delivery, when the fetuses are delivered minutes apart, many providers dont have much success billing for the second baby as a second delivery, even when they bill correctly for both deliveries by reporting the code that represents the highest valued global service provided along with a second code for vaginal delivery only (59409 or 59612).
For some payers, however, reimbursement comes only from using a single CPT global ob care code, one that most closely represents the more extensive delivery (i.e., vaginal  versus vaginal delivery after a previous cesarean delivery [VBAC, 59610] and cesarean versus failed trial of labor [59510 vs. 59618]). But the delay posed in Bradleys case will help in establishing that two distinct deliveries were performed. The correct code for twin two, delivered on Feb. 9 via cesarean, would be the global 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care). This code is reported instead of the global code for a vaginal delivery because it represents the most extensive service (i.e., there will be a longer follow-up period due to the cesarean delivery). Because it is unacceptable to bill twice for antepartum and postpartum care, a vaginal delivery charge only for the second twin is appropriate.
Catherine Brink, CMM, CPC, president of HealthCare Resource Management, a coding and reimbursement consulting firm in Spring Lake, N.J., points out that a modifier is needed for the second delivery. For the c-section delivery, says Brink, modifier -78 should be appended to 59510, to indicate a return to the operating room for a related procedure during the postoperative period (of the first vaginal delivery). You are informing the carrier that there was another procedure performed the day after the vaginal delivery. Brink explains that modifier -78 notifies the payer that a c-section is an additional procedure and should be paid as such even though it was performed during the global surgical period of the vaginal delivery.
ICD-9 Codes Support the Claim
The ICD-9 code(s) used for the deliveries will support the medical necessity of the procedures and ensure accurate reimbursement. Bradley indicates that the first twin was delivered vaginally by vacuum extraction using forceps. Additionally, the mother suffered from severe pre-eclampsia. Given those factors, the diagnostic coding sequence for twin one would read as follows. Code 669.51 (forceps or vacuum extractor delivery without mention of indication, delivered, with or without mention of antepartum condition) followed by 651.02 (twin pregnancy, delivered, with mention of postpartum complication) (because the second twin was not delivered at the same time) and 642.51 (severe pre-eclampsia, delivered, with or without mention of antepartum condition). The ICD-9 code for twin two would be 662.31 (delayed delivery of second twin, triplet, etc., delivered, with or without mention of antepartum condition).
Philip Eskew, MD, medical director of Women and Infant Services at St. Vincent Hospital in Indianapolis, points out that given the amount of time that elapsed between deliveries, physicians could bill for an additional inpatient evaluation and management (E/M) visit (99231-99233, subsequent hospital care, per day, for the evaluation and management of a patient ...). There is still a live baby in utero, says Eskew, and a prenatal hospital visit to assure that mother and fetus are doing well is appropriate. This is the same level of care you would give any baby in utero. You may not be able to charge for any additional prenatal care if the number of antepartum visits has not exceeded 13, but there is justifiable additional hospital care that can be billed. Because the situation itself is not routine, the additional visit in the hospital would not be considered part of routine postpartum care under a global code.
Lack of Global Coverage Is a Billing Twist
Most often when discussing antepartum care, delivery and postpartum care, coding and reimbursement specialists think in terms of global ob coverage. But in Bradleys case, the carrier insists that Brighams Surgical Center bill each segment of ob care separately, rather than in a global package. Even without the global billing, Bradley cannot bill twice for antepartum and postpartum care on the same pregnancy. But given that the deliveries occurred on separate calendar days, the system still allows her to bill twice for delivery. Therefore, she would apply codes 59426 (antepartum care only; 7 or more visits), 59430 (postpartum care only [separate procedure]), and then bill for the two deliveries. The first delivery is coded 59409 (vaginal delivery only [with or without episiotomy and/or forceps]), while the second delivery is coded 59514-78 (cesarean delivery only; return to the operating room for a related procedure during the postoperative period). Although Bradley did not attach the -78 modifier to the second delivery code, she told us she was successful in getting paid both for the ante- and postpartum care, and for the two separate deliveries.
Eskew reminds coders that when dealing with multiple births, it is best not to try to play the system when the payer refuses to pay for more than one delivery on the same day. You have to be straightforward about it, says Eskew. If twin one was delivered at 11:55 p.m., and twin two arrives at 12:05 a.m., although that is technically the next day, that is not the intent of the rules, and only one delivery should be billed. In the situation described, using the codes to tell the story of the deliveries should ensure appropriate reimbursement for the extra work involved.