Ob-Gyn Coding Alert


Pregnant Patient Switch Insurance? Here’s How to Handle Open Enrollment Season

Be prepared to potentially split up the global ob package.

As 2022 draws to a close, many employers begin to offer new healthcare plans to their employees and their families — which may mean your established pregnant patient, who has been coming in for all her antepartum visits, is now covered under a new insurance carrier. Do you know how to handle this?

Background: CPT® clearly states that when all or part of the antepartum and/or postpartum patient care is provided except delivery due to termination of pregnancy by abortion or referral to another physician or other qualified healthcare professional for delivery, you should only report the antepartum codes. This is easy to understand when the patient transfers to a new practice or the pregnancy does not develop to delivery.

But what happens when the patient stays with the same provider the entire pregnancy, but her insurance company changes before she delivers? Obviously, the complete care has been given by one provider or group practice, but two different insurance companies are now each responsible for payment for only a portion of the care.

Common: The most practical way to address this is to bill insurance A for the total number of visits the patient was seen during her coverage period with that company. Then insurance B will be billed based on its preference of either reporting the global package code (e.g., 59400) with a modifier 52 (Reduced services), or by billing separately the number of antepartum services they were responsible for followed by the appropriate delivery plus postpartum care code. In order to bill the antepartum care only, you need to understand the rules.

Prepare for coding your ob-gyn’s services up to the date of the patient’s insurance change depending on how many antepartum visits the physician provides — either one to three, four to six, or seven or more.

1-3 Visits Mean Office E/M Codes

Scenario: Your ob-gyn sees a pregnant patient for only one to three antepartum visits. How should you report this?

Solution: You need to report the appropriate evaluation and management (E/M) codes for payment.

First visit: For the first ob visit, don’t automatically look at a level-four established patient visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter).

You won’t have a set E/M code for the patient’s first visit. Your patient could be new to the practice, or the first visit may meet the criteria for a level-five established visit. Therefore, you should look to the entire code series (99202-99205 for new patients, 99211-99215 for established patients) as possible options, based on the physician documentation. It is a good idea to document the first three ob visits in the SOAP format as you would any E/M visit, just in case the patient does not go beyond these three visits. The ob flow sheet rarely documents enough elements of medical decision making (MDM) to support anything higher than a 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making ...).

Second and third visits: Your coding options are more limited for visits two or three. When Medicare and the American College of Obstetricians and Gynecologists (ACOG) were developing the relative value units (RVUs) for antepartum care, the follow-up visit was estimated to be a 99213, so this code is your best bet for each of these visits in the absence of documented problems.

Heads up: In some rare circumstances, such as when the patient has absolutely no problems during the visit and the ob-gyn performs or orders no diagnostic testing, the documentation might support reporting only 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making ... ) for each visit. But also, keep in mind that you may use total time as your selection criteria if well-documented in the record. For instance, 99214 would require 30-39 minutes of total time is spent on the date of the encounter, while 99212 only requires 10-19 minutes.

If the patient’s pregnancy is without complication, you should use one of the following codes:

  • Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester)
  • Z34.01 (... first trimester)
  • Z34.02 (... second trimester)
  • Z34.03 (... third trimester)
  • Z34.80 (Encounter for supervision of other normal pregnancy, unspecified trimester)
  • Z34.81 (... first trimester)
  • Z34.82 (... second trimester)
  • Z34.83 (... third trimester)

Watch out: Because you do not have a specific antepartum code for one to three visits and must report E/M codes, payers sometimes will deny these claims and tell you to “include in the global.” You are forced to appeal these decisions. Explain to the payer that you cannot report a global code because the patient has changed insurance and you are billing them only or the care they were responsible for.

4-6 Visits Mean Antepartum Code

Scenario: Your ob-gyn sees a pregnant patient for four to six antepartum visits. How should you report this?

Solution: Four to six visits means you’ll be flipping through your book to the maternity care and delivery section — particularly the antepartum codes.

You should report 59425 (Antepartum care only; 4-6 visits), which represents the total services rendered by your ob-gyn. This means that you’ll report only one unit of this code.

Rare case: Sometimes, you’ll encounter a payer that instructs providers to report a separate E/M service for the first ob encounter. You would need to have this in writing from your payer, and then you would need to meet the criteria of at least four additional visits to report 59425.

Note: Your diagnosis will be the same (Z34.0- or Z34.8-) unless the patient has any problem or complication.

7+ Visits May Mean Variation

Scenario: Your ob-gyn sees a pregnant patient for seven or more visits. The patient then transfers insurance. How should you report this?

Solution: You’ll find more variation in your coding choices for this scenario — but one thing is certain: you should avoid reporting the global package codes since you will not have performed the delivery during the time insurance A was responsible for payment. Because you’re talking about a patient who leaves the practice before delivery, codes 59400-59622 do not apply.

Option 1: For seven or more visits, CPT® has a specific code: 59426 (... 7 or more visits). You would include diagnosis codes Z34.0-, Z34.8-, or a code for any documented complications as appropriate during this time. That is, if the patient had a complication at any time during this time, the diagnosis code will change from routine pregnancy supervision to the problem or problems that were addressed.

Option 2: Some payers may ask you to report each visit separately. Good idea: Ask the insurer what “separate” means.

“Separate” may mean reporting 59426 along with a list of the dates. Therefore you should definitely keep track of a patient’s prenatal visits by noting the date the ob-gyn sees the patient. Keep in mind that 59426 was valued based on the assumption that it would include a maximum of 10 visits. Therefore, if the number of actual visits exceeds this, and because 59426 is a “surgical” code, the modifier 22 (Increased Procedural Services) might be appropriate to add if the documentation supports significant additional work.

The payer may also want you to report the appropriate E/M code for each visit, but that isn’t likely.