Ob-Gyn Coding Alert

Challenge yourself to see whether your delivery skills need brushing up.

A delivery claim doesn’t always mean reporting a global obstetric code. Sometimes you’ll encounter scenarios where your ob-gyn or nurse performed a delivery only, and you have to itemize this service.

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

Situation: 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’ll report O80 (Encounter for full-term uncomplicated delivery) and Z37.0 (Single live birth) assuming the baby was born head-first and there was minimal, or no assistance required.

Keep in mind: In billing one of these codes you should allow the patient’s regular ob-gyn to bill for the postpartum visits who will report Z39.2 (Encounter for 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).

 2. What to Do When Nurse Delivers Instead

Situation: 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

Situation 1: 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 1: 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 O30.001-O30.099 (Twin pregnancy …) based on specific trimester as well as the number of placenta and amniotic sacs and Z37.2 (Twins, both liveborn).

Situation 2: The ob-gyn delivers the first baby vaginally but the second by cesarean. How should you report this?

Answer 2: 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 23.53, and the RVU for 59510 is 68.24 — a difference of about $1,613.

The diagnoses for the vaginal birth will be O30.001-O30.099 and Z37.2.

For the second twin born by cesarean, use additional ICD-10 codes to explain why the ob-gyn had to perform the c-section — for example, O32.9XX0-O32.9XX9 (Maternal care for malpresentation of fetus …) or O66.6 (Obstructed labor due to other multiple fetuses) — and the outcome (such as Z37.2).

Situation 3: The ob-gyn delivers both babies by c-section. How should you report this?

Answer 3: 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 O30.001-O30.099 and Z37.2.

4. Check Your Complications Coding

Situation: 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 treatment for 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 O66-O77 series. For example, you might report O75.89 (Other specified complications of labor and delivery) or a more specific code that described the complication, if one was available.

ICD-10-CM codes and documentation are critical to maximize ethical reimbursement for these services, experts say.