Ob-Gyn Coding Alert

Prepare for 2014 by examining these ICD-10 diagnoses.

If you’re used to reporting deliveries with a global code, then you could find yourself startled when a claim lands on your desk requiring itemized codes.

Find out how to report delivery codes, and when you should apply modifiers like 51, 59 and 22 with these four scenarios.

1. Your Ob-Gyn Delivers for an Unaffiliated Ob-Gyn

Scenario: A pregnant patient’s regular ob-gyn is out of town when the patient goes into labor. Your ob-gyn, who is not affiliated with the regular ob-gyn, performs a normal delivery. How should you report this?

Answer: You should report the delivery according to how your ob-gyn performed it -- either vaginal (59409, Vaginal delivery only [with or without episiotomy and/or forceps]) or cesarean (59514, Cesarean delivery only).

As for diagnoses, you should use 650 (Normal delivery) and V27.0 (Mother with single liveborn) assuming the baby was born head first and there was minimal or no assistance required.

ICD-10: When your diagnosis coding system changes after October 1, 2014, you’ll report O80 (Encounter for full-term uncomplicated delivery) instead of 650 and Z37.0 (Single live birth) instead of V27.0.

Keep in mind: In billing one of these codes you should allow the patient’s regular ob-gyn to bill for the antepartum visits who will report V24.2 (Routine postpartum follow-up) to support these separately billed services. The delivery only CPT^® codes do not include postpartum visits in the hospital or discharge day management.

But if your ob-gyn provides all postpartum care services both in and out of the hospital, you should look to 59410 (... including postpartum care) or 59515 (… including postpartum care).

ICD-10: After your diagnosis coding system changes, code Z39.2 (Encounter for routine postpartum follow-up) will be reported instead of V24.2.

2. What to Do When Nurse Delivers Instead

Scenario: The nurse delivers the baby because the ob-gyn is in the next room doing a procedure on another patient. How should you report this?

Answer: You can use a global code (such as 59400). You should probably add modifier 52 (Reduced services) to account for the fact that the ob-gyn wasn’t present. Be sure to include information about which part of the process he did participate in, so you’ll lessen the impact of any fee reduction the payer might apply.

3. Master Multiple-Gestation Deliveries

Scenario A: One of your ob-gyn’s regular patients is having twins, and your ob-gyn delivers them both vaginally. How should you report this?

Answer A: You should report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; multiple procedures) for the second. Modifier 51 on the second code is key for reimbursement.

Caution: Some carriers require you to bill vaginal deliveries broken up into two separate codes with modifier 59 (Distinct procedural service) attached. Other payers will not pay anything additional for twin B when the delivery is vaginal, experts say. Nevertheless, your diagnoses will be 651.01 (Twin pregnancy; delivered, with or without mention of antepartum condition) and V27.2 (Twins, both liveborn).

ICD-10: Your twin delivery codes will explode in ICD-10. In 2014, ICD-10-CM will combine these codes into single options for twin pregnancy based on specific trimester as well as the number of placenta and amniotic sacs. Check out O30.001-O30.099 (Twin pregnancy …) instead of 651.01. For your outcome code, report Z37.2 (Twins, both liveborn) instead of V27.2.

Scenario B: The ob-gyn delivers the first baby vaginally but the second by cesarean. How should you report this?

Answer B: You should report 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care) for the second baby and 59409-51 for the first. Why: You should bill the cesarean first because 59510 has higher RVUs (relative value units). The RVU for 59409 is 24.58, and the RVU for 59510 is 69.87 -- a difference of about $1,540.

The diagnoses for the vaginal birth will be 651.01 and V27.2.

ICD-10: Again, you should check O30.001-O30.099 and Z37.2 for your ICD-10 options.

For the second twin born by cesarean, use additional ICD-9 codes to explain why the ob-gyn had to perform the c-section -- for example, malpresentation (652.6x, Multiple gestation with malpresentation of one fetus or more) -- and the outcome (such as V27.2).

ICD-10: You should check O32.9XX0-O32.9XX9 (Maternal care for malpresentation of fetus …) or O66.6 (Obstructed labor due to other multiple fetuses) instead of 652.6x after ICD-10 goes into effect.

Scenario C: The ob-gyn delivers both babies by c-section. How should you report this?

Answer C: When the doctor delivers all of the babies -- whether twins, triplets or more -- by cesarean, you should submit 59510-22. The reason you report only one code is that the ob-gyn is only making one incision.

Focus on this: Report 59510 with modifier 22 (Increased procedural services) appended. The ob-gyn performed only one cesarean, but the modifier shows that the ob-gyn performed a significantly more difficult delivery due to the presence of multiple babies. Be sure to include a letter of explanation for modifier 22 and the reason why you are asking for higher reimbursement along with a copy of the operative report.

Finally, for the diagnoses, include the reason for the cesarean, as well as 651.01, and V27.2.

4. Check Your Complications Coding

Scenario: During a vaginal and/or cesarean delivery, the patient has a complication. How should you report this?

Answer: For complications of pregnancy, the old rule “some are easy, some are hard” comes to mind.

If the complication required extra work (such as a third- or fourth-degree repair, or uterine atony after cesarean), you should report the main procedure code (such as 59400 or 59510) with modifier 22 appended. You should be able to explain the need for this modifier.

Heads up: When billing for complications of the delivery, you want to make sure you are using diagnosis codes in the 641-677 series. For example, you might report 659.81 (Other specified indications for care or intervention related to labor and delivery; delivered, with or without mention of antepartum complication) or a more specific code that described the complication, if one was available.

ICD-9 codes and documentation are critical to maximize ethical reimbursement for these services, experts say.

ICD-10: When your diagnosis coding system changes, you need to be specific about the complication, and you will find complications of labor and delivery in the code range 066-077. You’ll see that 659.81 crosswalks to a single option in ICD10:  O75.89 (Other specified complications of labor and delivery).