Ob-Gyn Coding Alert

Postpartum checks are a normal part of global obstetrical care, but often these visits are more complicated than what is considered routine, and in such cases coders may miss opportunities for additional reimbursement.
 
During a routine postpartum check, the physician performs a history and physical and interviews the patient to determine her overall postpartum status. This discussion frequently covers contraception, breast-feeding or other questions the patient might have related to the aftermath of her pregnancy. Although it is the equivalent of an E/M visit, the postpartum check is included in the global package.
 
According to the American College of Obstetricians and Gynecologists' (ACOG) Ob/Gyn Coding Manual, postpartum services include "a recovery room visit, uncomplicated inpatient hospital postpartum visits" and, most important, "uncomplicated outpatient visits until six weeks postpartum."
 
Alternatively, those services not included in routine postpartum care are "management of inpatient or outpatient medical problems not related to the pregnancy, management of inpatient or outpatient medical problems or complications related to the pregnancy, management of surgical problems arising in the postpartum period and tubal ligation."
 
Given these guidelines, coders must determine with their physicians what is and isn't routine for postpartum care. Once you determine that a visit was not routine, you must choose the right code and/or modifier to bill the service. "When there is clearly a complication or problem in the patient that's outside the realm of global ob care, that's fairly straightforward from a coding perspective," says Melanie Witt, RN, CPC, MA, an independent coding educator and ob/gyn coding expert based in Fredericksburg, Va. These might include a case of influenza, upper respiratory infection, etc. "But there are always gray areas that make coding decisions a bit more challenging."

 
A patient who had a routine pregnancy and delivery reports for her postpartum checkup. The ob/gyn documents in his or her notes that the patient is breast-feeding, has not had a period yet and has a good energy level. The physician also notes the topics of their discussion:
 

Vaginal dryness. The physician mentioned the possibility of vaginal dryness while breast-feeding, and the patient said she would tell the doctor if it becomes a problem.
 

Contraception. The patient was scheduled to resume oral contraceptives and was told that she might have a long delay in menstruation as long as she continues to breast-feed.
 

Breast mass. The patient had a breast mass that the physician suspected was a blocked duct. The ob/gyn advised her to check it monthly and return in three months for a recheck.

Hyperthyroidism. The patient had undergone radioablation for Grave's disease. The physician ordered a thyroid stimulating hormone (TSH) test and said he or she will contact the patient when the test results are in to see if her prescription for thyroid medication (Synthroid) must be changed.  
 
Discussion of vaginal dryness and contraception is generally considered routine follow-up to a pregnancy.  The patient did not report with vaginal dryness -- the physician merely mentioned the possibility of this symptom occurring. And while aspects of the postpartum visit described are considered routine care, discussion and treatment of hyperthyroidism and a breast mass are not. 
 
"I would say this is not a routine postpartum check," says Jan Rasmussen, CPC, president of Professional Coding Solutions, a medical coding consulting company in Eau Claire, Wis. "The note implies that the patient has two problems -- hyperthyroidism status postablation and a breast infection." Per ACOG's guidelines, "complications related to the pregnancy," i.e., the breast mass, and  "medical problems not related to the pregnancy" are billable outside of the global package.
 
"By selecting and documenting the problems that are not related to recovery from delivery (the breast duct and hypothyroidism), the visit becomes an E/M in addition to a postpartum check," Witt says. The above postpartum check would be internally recorded as 99024 (or the practice can make up its own "dummy" code) but not billed, and the E/M portion of the visit would be coded to the appropriate level with modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) appended. Witt says that the E/M level assigned can be based only on the history and medical decision-making associated with the two "problems" or conditions: the breast mass and the hyperthyroidism.   
 
"This may include the history of the complaint and illness and a pertinent-system review related to the problems. There might also be an examination of the breast and neck, and of course medical decision-making regarding the two problems will be documented." Witt adds that the documentation showing the E/M service for the problems should be clear. A separate note or at the very least a separation of the postpartum-visit documentation from the problem documentation will ensure that the correct level of E/M code is billed and that the service is clearly not related to recovery from the delivery.

 
There are many complications unrelated to pregnancy for which an E/M service could be carved from the postpartum visit. But for all other circumstances of routine postpartum care, the visit is included in the global charge. The exception to this occurs only if the practice is not billing for global care and is instead billing each antepartum and postpartum visit, as well as delivery, as separate items. Although the ACOG manual lists post-delivery as the range for the postpartum visit to occur, Witt says that three months (12 weeks) is more the norm. "In my teaching," Witt says, "the postpartum visit is part of the global unless the patient does not show up for more than three months after delivery and the physician has documented attempts to get the patient in for her visit prior to that. Then the patient is no longer postpartum in anatomy so it is OK to bill it as an E/M service."
 
Some carriers may have policies that require that the postpartum visit be included in the global fee no matter when it occurs, and coders should check for this before billing. Since it's not unheard of for patients to come to their postpartum check with news of a positive home pregnancy test, delineating "included or not included" is critical to effective reimbursement.