Ob-Gyn Coding Alert

Some obstetrical patients require more visits, time and work from the ob/gyn practice than would be usual. How can this patient be financially recognized? Many ob/gyn practices do not realize that they are entitled to receive increased reimbursement when providing additional visits outside of the normal global ob package, says Liza Green, RRA, CCS-P, Coding Compliance Specialist for the John C. Lincoln Health Network in Phoenix, Arizona. In addition, Green points out that many ob coding professionals dont understand how to code and bill for high-risk or complicated obstetrical care.

Routine Global OB Care

Prior to understanding how to bill for complicated ob cases, the coding professional should be aware of the services that are considered part of the normal ob global package in codes 59400, 59510, 59610 and 59618. Based on CPT definitions, antepartum visits include such elements as reviewing the patients history, performing the physical exam, monitoring the patients blood pressure and weight, assessing the fetal heart tones, and checking routine urinalysis. The usual schedule of visits for the uncomplicated case includes a monthly ob visit up to the 28th week, biweekly visits to 36 weeks gestation, and weekly visits thereafter until the patient delivers (13 visits on average with a range of 10 to 15 total antepartum visits). Postpartum (also called puerperium) care includes hospital and office visits following delivery. Once discharged from the hospital, most patients only require one postpartum visit at four to six weeks after delivery. When a patients condition requires more visits, the CPT states these additional visits or services should be coded separately and, according to Green, practices should expect to be paid for these extra services.

Coding for Complicated Care

A number of conditions might complicate a patients antepartum or puerperium periods, such as gestational diabetes, preeclampsia, hyperemesis, pre or postpartum bleeding, premature rupture of membranes, fetal distress or infections. These conditions often require more work and exceed the global package. But the extent to which this will occur is often not fully calculable until after the delivery. Therefore, many ob offices will wait until that point and take a look at all the services provided during the antepartum and/or postpartum period before submitting any claims.

Once a global period for any ob patient is complete, a practice should have a system for carefully reviewing the patient records to ensure that any charges beyond the global are coded and billed. According to Green, this is an area of lost revenue in many ob/gyn practices.

Once these services are found, they should be coded and billed, using the appropriate Evaluation and Management (E/M) or Medicine CPT codes, based on the care provided at the visit. The ICD-9 diagnosis codes linked on the HCFA-1500 claim form (boxes 21 and 24E) to the visit CPT codes should demonstrate the reason for the additional visits. These additional services can be added to the claim that includes the global service, or they can be submitted as an additional claim.

For example, consider a 33-year-old patient, gravida 3, para 2 (both normal spontaneous vaginal delivery [NSVD] full term), is seen in the office 19 times due to developing preeclampsia. After the delivery, the ob coder reviews the case and finds that the patient required six additional visits (beyond the usual 13) for this care. The documentation for three of these visits supports billing for E&M code 99212, while three of the visits have more extensive documentation that supports billing E&M code 99213.

In addition, after delivery of the baby, the patient experiences prolonged pain and irritation due to a hemorrhoid. She is seen by the ob/gyn physicians office for band ligation of the hemorrhoid at two weeks post-delivery. Finally, the patient is rechecked at her six weeks postpartum visit.

When coding for this patient, remember the claim form must note both the CPT codes describing the additional services, as well as the ICD-9 diagnoses that depict why the additional services were needed.

CPT ICD-9
59400 linked to 642.41

Note: You cannot use the Dx 650 if there were any problems during the episode of delivery; in this case, the patient was preeclamptic, which would have complicated both the pregnancy and delivery.

CPT ICD-9
99212 linked to 642.43
99212 linked to 642.43
99212 linked to 642.43
99213 linked to 642.43
99213 linked to 642.43
99213 linked to 642.43
46221 linked to 671.84

While this example discusses submitting the claim for additional services at the completion of the global period, some ob practices may choose to submit the claims for the additional visits or services during the pregnancy. This method may be useful to improve cash flow for the practice, rather than holding the revenue for the claims until the end of the global period. Just as you would complete the claim at the end of the global period, the CPT codes for the additional visits or procedures should be matched with a corresponding ICD-9 diagnosis code describing the patients complication. However, if you are paid additionally for these services, but the patient delivered early so that the total number of antepartum visits did not exceed the global package, you will have to consider returning some of what turned out to be an overpayment.

Reimbursement Concerns

The ob/gyn coder should be aware that some carriers may have specific guidelines for the visits or other services they will pay for outside of the global ob package. Review your contracts to verify when additional items will be covered. Encourage the practitioner to provide good documentation supporting the need for the additional services. Note that the term high-risk may represent a current complication or it may involve a concern that the pregnancy may not go well due to previous history. Payers generally recognize complications, but they do not allow extra for the physicians merely worrying about the pregnancy when nothing untoward actually occurs.

Primary Care in the Ob/gyn Office

In addition to coding and billing issues for the high-risk or complicated pregnancy, some on-gyn physicians who also provide primary care may see their obstetrical patients during their pregnancy for other health concerns unrelated to the pregnancy. For example, when an ob patient requests to be seen for treatment of an upper respiratory infection or pharyngitis symptoms, the additional office visits should be individually coded. These visits would always be coded at the time they occur.