Ob-Gyn Coding Alert

Postpartum office visits typically include a discussion about contraception. Often this is a simple discussion, with the patient stating that she wishes to go back on oral contraceptives. However, when a patient says she is considering tubal ligation, a subdermal implant, intrauterine device or other form of contraception, the simple discussion becomes a much more involved process, for which there is no additional reimbursement for time spent with the patient. An alternative to discussing contraceptives in the postpartum visit is scheduling a follow-up visit to discuss and prescribe contraception.

Thomas Kent, CMM, principal of Kent Medical Management in Dunkirk, MD, and a former practice manager, offers the following example: He recently completed a large coding review for a five-doctor, three-nurse/midwife practice. The review found that they were losing significant reimbursement potential in the way they conducted postpartum contraceptive counseling.

When they conducted postpartum checks, says Kent, they always asked the patient, What are your plans for contraception? This works fine when the patient says she wants to resume her previous method. But what about when a patient says, I think I want to get my tubes tied? This becomes a much longer discussion.

Time is Money

Kent reasons that since a discussion about tubal ligation or other more involved methods of contraception can easily take 20 minutes or more of unscheduled time, physicians lose both money and time with the postpartum visit. He suggests physicians schedule a follow-up visit strictly to discuss contraceptive options. That way, the patient is given the time needed to learn the full range of options, and practices stay on schedule and have a much greater chance of being reimbursed for their time spent with the patient.

Clearly, doctors want to do what is convenient for their patients and themselves. Very often its easier to discuss contraceptive care at the time of the postpartum follow-up. But a strategic decision must be made on how best to serve patients while ensuring the maximum reimbursement. With global ob care now paying out as little as $1,500 total, often with no differential for a cesarean section or other additional procedures, practices need to be mindful of extra time spent in postpartum care.

Doctors must ask themselves, says Kent, Will I risk losing this patient by insisting on an additional office visit to discuss contraception? I dont think they will. Considering the money and time now being lost through extended contraceptive counseling, my bet is that at worst a break-even point would be reached.

Use Modifier -24 During Global

If the follow-up to discuss contraception occurs within the normal global period, which is six weeks for most payers, use 59400 (routine obstetric care with vaginal delivery and postpartum care), then a -24 modifier (unrelated evaluation and management service by the same physician during a postoperative period) must be used, as the office visit is separate from postpartum care.

The -24 modifier applies when the office visit is for something other than what global coversnon-routine follow-up or treatment for something that is not related to the surgery or procedure that created the global treatment period. If the visit falls outside the global period, then no modifier is required.

Inside the global period, the code for an office visit with the use of the -24 modifier will indicate to the insurer that the counseling session was non-routine. Without the modifier, the visit would automatically be rejected.

Whether inside or outside of the global period, coding for the contraceptive counseling is based strictly on face-to-face time spent with the patient. The codes you should use are 99212-99215 (office visit for an established patient), based on the amount of time spent. The more time spent in counseling, the higher the code and greater the reimbursement.

Documentation is Vital

With any of the applicable codes, documentation of the visit is critical for reimbursement. Coders must indicate the amount of face-to-face time spent with the patient and describe the content of the counseling session as well as any brochures or pamphlets provided. When a doctor gives the patient a pamphlet that discusses contraceptive options, physicians can indicate that the pamphlet was reviewed without having to give an in-depth description of the counseling. If no pamphlet is available, then a detailed outline must be provided.

The diagnostic code for this visit is V25 (encounter for contraceptive management), followed by the appropriate suffix depending on the treatment prescribed (.01 for oral contraceptives, .02 for initiation of other contraceptive measures).

The Opposing View

Carla Bryan, CPC, of Womens Care of Hartsville, SC, feels a separate contraceptive counseling session that falls within the global period (with a -24 modifier) would not be reimbursed. We would not charge for that [or hold a separate counseling session] because everybody rejects it, says Bryan. Bryan says that only Medicaid, which codes antepartum, delivery and postpartum care as separate procedures, would accept the charge. Primary insurers would not honor it, Bryan says.

Melanie Witt, RN, CPC, MA, program manager in the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC, concurs with Bryan. [ACOG] believes that contraceptive counseling post-delivery is included in the global obstetric package and we do not endorse it being coded outside of the global.

However, the definition for code 59400 does not specify that postpartum care includes contraceptive counseling, and Kent is challenging the assumption that it routinely should. If contraceptive counseling is a non-covered service, then doctors can charge the patients directly if they feel the discussion warrants a separate visit. Otherwise, if the service is non-allowed, it is included in the global plan as specified by your contract and cannot be billed separately. Ultimately, the answer is to question all services included in the global obstetrics package before signing on with a managed care company. And, since many plans exclude coverage for contraceptive care, says Kent, Doctors should not feel guilty about charging the patient for services not covered by their plan.