Ob-Gyn Coding Alert

NSTs monitor the fetus while labor checks assess the mother.

If you are reporting 59025 when the ob-gyn checks to determine if a patient is in labor, you may not be coding accurately, even though the procedures are similar.

Ob-gyns often use a fetal monitor to determine if a woman is in labor. They use the same device for a fetal non-stress test (NST, 59025). But there are significant differences between the two procedures that require distinct approaches to coding.

Use 59025 for NST Only

To understand why you can't use 59025 for labor checks, first review what an NST involves. During the procedure, the ob-gyn monitors the fetal heart rate using external transducers. A "reactive" NST will show the fetal heart rate accelerate from the baseline 15 beats per minute for a minimum of 15 seconds at least twice during a 10-minute window. If there are no accelerations after 20 minutes, the ob-gyn may attempt to induce a fetal response with acoustic stimulation through the mother's abdomen or a vibration that would awaken the baby or cause it to react to the stimulus. This stimulation might be repeated every five minutes for a maximum of two to three times. If there are still no accelerations of the fetal heart rate, then it is interpreted as a "nonreactive" NST.

Difference: NST differs from "routine" monitoring in that the patient is asked to mark fetal movements on the monitor strip (or with newer equipment, fetal movement is detected and marked on the strip), which the physician then interprets as generally reactive, nonreactive, and perhaps "equivocal," experts say.

Therefore, when the ob-gyn performs an NST to determine fetal well-being, you should report 59025. According to Medicare's 2012 Physician Fee Schedule, the procedure carries 1.42 relative value units, meaning it's worth approximately $48.33.

On the other hand, an ob-gyn can perform an NST for a patient in the early stages of labor if a problem with fetal well-being is suspected. But remember that the test must include an indication of fetal movements and the physician must interpret the strip and write (or dictate) a report, which must be entered into the patient record. In other words, it is not enough to put the patient on the monitor and bill for an NST.

The NST is a valuable tool to be reassured that the baby is doing fine. Spontaneous accelerations in response to an active baby are not only reassuring to the physician but often are an education to the mother: "That's the baby moving? I have felt that before but didn't know it was the baby moving."

Include Labor Checks in Global

So the question remains: How do you get reimbursed for labor checks if you don't use 59025?

If the patient is at term, in labor and the ob-gyn admits her for delivery, the labor check is included as part of the global ob package (for example, 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care).

On the other hand, the physician may perform a labor check and then request an NST to be reassured that the fetus is well before sending the patient home. Most NSTs are performed when the patient states that she has not felt the baby move very much or the mother is past 40 weeks 0 days, experts say. As long as the patient does not deliver within 24 hours of admittance, the reimbursement for the labor check would be included in the initial hospital care (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...). Because the ob-gyn did not admit the patient for delivery, he or she can report the initial care separately from the ob global period.

If the patient delivers less than 24 hours after admittance, however, you should again consider the labor check part of the ob global care. Consequently, you should not bill it separately.

3 Scenarios Test Your NST, Labor Check Skills

Take the following coding quiz to cement your skills for telling the difference between a fetal non-stress test (NST) and a labor check. Make sure you know what codes to report in each situation.

Scenario 1: A patient presents whose water has broken, but she doesn't feel any contractions. She's in week 38 of gestation and has dilated 3 cm. Prior to admission, the ob-gyn evaluates the baby with a fetal monitor to be reassured that the baby is OK and the mother is not having contractions.

Solution: In this case, the physician uses the external transducer to determine the mother's condition. He did not use it to assess the fetus. Therefore, you should include the labor check as part of the global ob package (for example, 59610, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery).

Scenario 2: A patient at 30 weeks of gestation comes to the doctor's office complaining that her fetus has not been moving much in the past few weeks. The ob-gyn places the external transducer and performs an NST, using an electronic larynx to stimulate the fetus with noise through the patient's abdomen when there are no fetal heart rate accelerations with movement during the first 20 minutes of monitoring.

Solution: You would report this service with 59025. The ob-gyn uses the NST to determine the status of the fetus. The procedure takes longer than a labor check and requires repeated stimulations to assess the specific fetal reaction or lack thereof.

Scenario 3: A patient at 32 weeks' gestation presents in labor. The ob-gyn admits her to the hospital and places the external transducer on the woman's abdomen, giving her medication to halt the labor. Based on the readings from the transducer, the labor stops.

Solution: Here, you should include the labor check in the hospital admit (99221-99223). As in the first scenario, the ob-gyn did not use the external transducer to examine the fetus' condition, but to monitor the patient's contractions. Therefore, you would not report a separate NST.