Ob-Gyn Coding Alert

Overcoming the Reimbursement Challenges of the Diabetic Ob Patient

Pregnancy with diabetes as a complicating factor requires that extra monitoring and often additional procedures be conducted by the ob-gyn. Two to three percent of all pregnancies have diabetes as a complicating factor, with more than 90 percent of these occurring as gestational diabetes. When managing either gestational or preexisting diabetes in the pregnant patient, additional care and monitoring are required to ensure a safe and relatively routine pregnancy and delivery. But to hear coding experts tell it, monitoring the pregnancy can be the easy part. The difficulty arises when ob-gyn practices seek reimbursement for the wide range of extra time and services required for the diabetic pregnant patient.

The biggest difference between a diabetic and non-diabetic ob-gyn patient, with regard to treatment, is that the diabetic patient must be in constant communication with her doctor. Pregnant diabetic patients fall into one of the following categories, each of which requires substantial management on the part of the physician:

1. Established diabetes type I or II, controlled. These patients are likely to be the easiest to monitor and control, as they are already familiar with the necessary methods of managing their preexisting diabetes.

2. Established diabetes type I or II, uncontrolled.Patients whose preexisting diabetes is not being controlled through medication and diet will need additional counseling and monitoring. Pregnant women with uncontrolled diabetes tend to have bigger babies, thus cesarean sections are more common. Gestational diabetes can often go undetected well into the pregnancy. Patients new to diabetes require significant counseling and education in order to establish a controlling regimen of care throughout the pregnancy.

Building a Case for Reimbursement

Extra office visits required for a diabetic ob-gyn patient are a common sticking point when it comes to reimbursement. Diabetics tend to be seen much more frequently because of risks to mother and fetus. It is typical for the obstetrician to see the patient every other week for the first seven months, then even more frequently during the last two months of pregnancy. In some cases, during the last two months of pregnancy, the patient goes to the hospital for a fetal non-stress test (59025-26 [professional component]) every other day.

The issue with a diabetic ob-gyn patient, says Melanie Witt, former program manager of the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG), is that the ob-gyn is essentially taking over the diabetes management and should be reimbursed for it. An office visit for the management of diabetes is not included in the global ob package and should be billed as an E/M encounter, says Witt. The real issue is not how to code, but how to get reimbursed. It is an issue of coverage and convincing the payer that treatment of diabetes is separate from the global package and requires a higher level of management skill.

Witt continues, Most of the headaches come from not being able to bill for the additional visits or tests that will be required to manage the pregnancy. So the issues are how to bill for visits that are for controlling the diabetes only, Witt explains, and how to code separately for the additional blood work, ultrasounds, etc.

Billing Additional Visits

Also at issue is diagnostic coding because the code for diabetes with pregnancy is found in the ob-gyn chapter of ICD-9-CM, but even though you report a second code to show the type of diabetes, some payers will not pay any additional services because you have used a pregnancy code.

Barbara J. Cobuzzi, MBA, CPC, is president of Cash Flow Solutions, a medical billing and coding consulting firm in Lakewood, N.J. She encourages all ob-gyn practices to have a policy of the number of visits they consider as part of the global packageshe generally recommends 12 visits for her ob-gyn clients. If a diabetic patient is visiting her doctor every other week, says Cobuzzi, and even more frequently than that in the third trimester, then obviously, many visits will fall outside of global. She generally recommends that practices bill every other visit as an office visit coded separately from the global package. Witt notes, however, that ACOG does not advise billing for additional antepartum visits until the patient has been seen at least 13 times, but any visit dealing only with diabetes management should be billed at the time of the visit.

Cobuzzi says that doctors have to be thorough with their documentation of these extra visits (outside of global). Code 99212 (office or other outpatient visit, established patient, problem-focused history and examination, straightforward medical decision-making) is generally the standard for the non-global E/M visit, explains Cobuzzi. If the doctor (or office/coding manager) wants to bill for a 99213 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) or 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity), they will need to provide extra medical justification for the higher levels and subsequent visits. If there are other problems, such as a patient whose diabetes is uncontrolled and requires hospitalization or training, then document time spent with the patient and bill for the higher level visit using the time rule.

Cobuzzi also points out that some ob-gyns working with high-risk patients (and maternal-fetal specialists in particular) have negotiated for high-risk global packages with their payers. They bill for an all-inclusive global and get paid more, and are saved the hassles of trying to convince the carrier to pay for the extra E/M visits.

Quick Coding Reference Guide

For the diabetic ob-gyn patient, the following diagnostic codes are needed, in addition to the appropriate CPT global package code:

The diagnostic code for the pregnancy is 648.03 (diabetes mellitus complicating pregnancy).

An additional code from the 250 code category is required to identify the type of diabetes. For instance, the code 250.0 would be reported if the diabetes itself was not complicated. A fifth digit for the type of diabetes (insulin versus non-insulin dependent and controlled versus uncontrolled diabetes) would also be required.

The diagnostic code for gestational diabetes is 648.8 (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; abnormal glucose tolerance; gestational diabetes) [note: a fifth digit (0-4) is required for this code, to indicate the episode of care].

The following tests are often required as part of the management of a diabetic ob-gyn patient:

- hemoglobin A1C (82820; hemoglobin-oxygen affinity),

- alpha-fetoprotein (AFP) (82105 or 82106; alpha-
fetoprotein; serum, alpha-fetoprotein; amniotic fluid

- ultrasound (76805-76828; [depending on method and approach]),

- electronic fetal monitoring (59051; fetal monitoring) when performed by the non-attending physician. When performed by the attending physician, this service is included as part of the global package,

- amniocentesis (59000; amniocentesis, any method),

- fetal non-stress test (59025; fetal non-stress test),

- test for spina bifida (i.e., 82013, acetylcholinesterase or 82105, alpha-fetoprotein; serum/82106, alpha-fetoprotein; amniotic fluid).

Planning Ahead Avoids Future Problems

Cobuzzis primary recommendation for avoiding reimbursement nightmares with diabetic ob-gyn patients is to know in advance what your contract with the insurer says. According to CPT 2000, several of the procedures associated with pregnant diabetics are not covered under global care packages. Cobuzzi says that some contracts do include everything, and when they dont, its time to renegotiate. Cobuzzi explains: The important thing to remember here is that when the time comes to renegotiate your contract with the payer, you have made a list that includes every denial. These items are the things you will ask for in your renegotiated contract. You may want to negotiate a separate global for high-risk patients that includes more services, and/or negotiate the right to bill and be paid for these higher risk and high resource patients. The data you have saved on past cases will help in this regard. It may not help you in the short run, but at least maybe next time, an identical or similar claim wont be denied.