Ob-Gyn Coding Alert


Shatter 5 Myths to Slash Potential Delivery Coding Errors

Here’s why you need to keep modifier 59 handy.

Are you relying on global codes when your ob-gyn or hospital nursing staff performs a delivery? If so, you’re setting yourself up to make a costly mistake. Sometimes extenuating circumstances require you to choose from itemized delivery codes and use modifiers like 51, 59, and 22.

Face these five delivery myths and uncover the coding reality.

Myth #1: Out-of-Town Ob-Gyn Means You Code Global

Here’s the situation: your 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. If you think this gives you leave to report a global ob code, then you’re setting up your claim for disaster.

Reality: 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), says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

As for diagnoses, you should use O80 (Encounter for full-term uncomplicated delivery) and Z37.0 (Single live birth) for a vaginal delivery. These are among the prime diagnoses for deliveries without complications. If the situation calls for a cesarean, you will be reporting a complication code that indicates the reason for the cesarean (for instance, O34.21, Maternal care for scar from previous cesarean delivery) with the appropriate outcome code (such as Z37.0).

You should allow the patient’s regular ob-gyn to bill for the antepartum visits. The delivery-only CPT® code does not include rounding visits in the hospital, nor discharge which would be coded separately per CPT® instructions.

Extra: If your ob-gyn provides all postpartum care services both in and out of the hospital, you should look to 59410 (... including postpartum care). Use Z39.2 (Encounter for routine postpartum follow-up) as an additional supporting diagnosis.

Myth #2: Nurse Delivery Means Delivery Code Only

Suppose the nurse delivers the baby because the ob-gyn is in the next room doing a procedure on another patient. Don’t fall into the trap of thinking the nurse is providing a separately reportable service.

Reality: No one can bill the delivery. You can use a global code (such as 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care). 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.

Myth #3: 2 Vaginal Deliveries Means 2 Global Codes

One of your ob-gyn’s regular patients is having twins, and your ob-gyn delivers them both vaginally. Two deliveries, however, do not mean you should submit two global ob codes.

Reality: You should report the global code (59400) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; Multiple procedures) for the second.

Heads up: You should know your payers’ preferences. Some insurance companies instead prefer that you bill the additional delivery with modifier 59 (Distinct procedural service) attached. Other payers will not pay anything additional for twin B when the delivery is vaginal.

Nevertheless, your diagnoses will be O30.0- (Twin pregnancy …) and Z37.2 (Twins, both liveborn).

Myth #4: Vaginal, Then Cesarean? Bill in Order

The ob-gyn delivers the first baby vaginally but the second by cesarean. Even though the ob-gyn performed the vaginal delivery first, that does not mean you should report this code first.

Reality: 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 RVUs for 59409 are 24.11 ($781.37), and the RVUs for 59510 are 79.54 ($2,577.77).

Red flag: When the codes are submitted with the lower code first, many payers will pay that at 100 percent of the allowable but discount the second code by 50 percent. This could mean as much as $1796.40 in reduced revenue (based on the Medicare conversion factor of 32.4085 per RVU).

The diagnoses for the vaginal birth will include O30.0- 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, malpresentation [O32.9xx- (Maternal care for malpresentation of fetus …]) and the outcome (such as Z37.2).

Myth #5: 2 C-Sections Mean 2 Codes

The ob-gyn delivers twins by cesarean. Although you may be tempted to report two codes for two c-sections, you would risk over-reporting your ob-gyn’s work.

Reality: When the doctor delivers all of the babies — whether twins, triplets, or more by cesarean, you should submit 59510-22 (Increased procedural services). The reason you report only one code is that the ob-gyn is only making one incision.

Highlight: The ob-gyn performed only one cesarean, but modifier 22 shows that the ob-gyn performed a significantly more difficult delivery due to the presence of multiple babies. Important: You will need supporting documentation.

Finally, for the diagnoses, include the reason for the cesarean (e.g., O30.0-) and Z37.2.

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