Ob-Gyn Coding Alert

Some In-hospital E/M Care Prior To Delivery Is Billed Separately

When an ob patient enters the hospital for delivery, and that delivery takes 24, 48, 72 or more hours, just how much of her care during that time is included within the global package? Is the entire time regarded as part of global or are certain services and procedures billable separately from global care as evaluation and management (E/M) care?

Scenario: An elderly primigravida with chronic pain and hypertension unrelated to the pregnancy is admitted to the hospital at 6 a.m. Tuesday for the purpose of inducing labor. The ob/gyn brakes the patients amniotic sac and administers an IV of Pitocin. After the patient is on the Pitocin drip for 14 hours, the contractions are still minor and not accelerating. The ob/gyn takes the patient off the Pitocin IV, then restarts the IV several hours later, for another 20 hours. At 3:30 a.m. Thursday the physician decides to conduct a c-section. The pregnancy is delivered at 8 a.m. Thursday without complications to mother or baby.

Whats In and Whats Out With Global Billing?

After hearing the above patient scenario, Laurie Castillo, MA, CPC, of Physician Coding and Compliance Consulting a Manassas, Va.-based medical practice consulting firm, concluded that everything before the last 24 hours prior to delivery was billable outside of the global package. Castillo explains: Global ob care is considered everything within the range of normal. When antepartum care goes above and beyond what is considered normal, especially with inpatient services, those services can be billed separately.

The rule of thumb is that everything prior to the last 24 hours before delivery potentially is billable outside of global. The key then is to identify the levels of evaluation and management (E/M) care and document medical decision-making to make a good case for a hospital admission that did not result in a delivery for several days.

Castillo brakes down the individual services and diagnoses that apply in the above case. The billing sequence would begin with an inpatient admission and then describe the reasons for each procedure and medical decision up until the time of delivery.

CPT codes 99221-99223 (initial hospital care, per day, for the evaluation and management of a patient which requires these three key components; ranging from a detailed to a comprehensive history, a detailed to comprehensive examination and medical decision making that is straightforward or of low complexity to high complexity) would apply for the patients admission. The coder also would need to include the reason for admission. In this case, the doctor felt that the patients hypertension was severe enough to warrant an induction of labor. Though pre-existing and not gestational, the hypertension would be coded as a complicating factor, using ICD-9 code 642.03 (benign essential hypertension complicating pregnancy, childbirth and puerperium; antepartum condition or complication). This would be listed as the first reason for admission.

Following hypertension, the second reason for admission would be code 658.33 (delayed delivery after artificial rupture of membranes; antepartum condition or complication) because the patient was brought to the hospital to begin labor by breaking her water.

On the second day of the patients stay, which when working with a 24-hour clock began Wednesday at 6 a.m., the ob/gyn ruled the inducement a failure, and decided to perform a cesarean section. When coding the c-section, the coder would need to list 659.11 (failed medical or unspecified induction; failure of induction of labor by medical methods, such as oxytoxic drugs [Petocin]) as the reason for the c-section. This would be in addition to the global code 59510 (routine obstetric care including antepartum care, cesarean delivery and postpartum care).

If Its Not Routine, Its Not Global

The word routine in the definition of 59510 is the important factor here. Castillo argues that anything considered outside of routine care also is considered outside of global careand therefore billable.

Evelyn M. Gross, CMM, CPC, NR-CMA, manager of physician practices and new business at Bayshore Community Health Systems, a hospital-based system of healthcare centers with locations throughout New Jersey, says her approach to this scenario hinges on the use of the -22 modifier (unusual procedural services). I dont believe you can use modifier -22 on the E/M code for the hospital admission, so I would attach it to the code for global care with a c-section, 59510. When a doctor starts a Pitocin drip, Gross explains, it usually doesnt take so long for the baby to kick in and decide its ready to deliver. This patients water was broken for more than 24 hours, so were getting into a risk of infection to the motheran already high-risk pregnancy just becomes more high-risk, at which point the ob/gyn decides to do a c-section.

The -22 modifier indicates a level of service greater than what is usually provided with a listed procedure, says Gross. When attached to the global ob code, youre essentially saying that this was normal in every other way; the c-section went without complications, and that both mother and child were fine. But using the -22 modifier along with the proper ICD-9 codes will explain the extra work that was done and explain the doctors thought process as well.

Melanie Witt, RN, CPC, MA, former program manager of the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG), recommends that in this scenario, coders keep the -22 modifier and lose the E/M submission code altogether. My hunch is that most insurers are going to look at this and say, Hey, the H&P [history and physical examination] component of the hospital admission code (99221-99223) is already a part of the global package. You would do an H&P when you admitted the patient for labor, induced or natural, so theyre not going to give you any extra money for something they feel is a normal part of global anyway. Witt agrees with Gross that the -22 modifier appended to the global ob code will signify the extra work involved and, ideally, boost reimbursement.

Gross recommends that coders look to their carrier contracts and policies and see what their guidelines are concerning delivery. Some carriers dont care if its a vaginal or a cesarean delivery, says Gross. Theyre going to pay the same either way. Others might not only pay a higher rate for a c-section, but also pay for the prolonged services.

Documentation is the key again in this coding scenario, Your doctor always needs to write plenty of back-up, notes that describe his thought process, what he ruled out, what he ruled in, says Gross. Plus, your ICD-9 codes will indicate the sequence of eventswhy the patient was induced, that an induction occurred and the failed induction resulted in a c-section. Let the ICD-9s tell the story to make your case for reimbursement.