Ob-Gyn Coding Alert

Key: Reports should use simple, straightforward language.

If you’ve ever filed an ob-gyn claim using an unlisted procedure code, you know how much effort is involved. To ensure that your physician gets reimbursed for procedures without specific codes, experts say to follow these four pointers:

Describe the Procedure in Plain English

Anytime you file a claim using an unlisted procedure code (for example, 59899, Unlisted procedure, maternity care and delivery), you should include a separate report that explains, in simple, straightforward language, exactly what the physician did.

Insurers consider claims with unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don’t always dictate the most informative notes.

Part of the coder’s job when preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman’s terms. Be careful to avoid or explain medical jargon and difficult terminology, because this has already been provided in the procedure/operative note that you must send with the claims, says Donna C. Kroening, CPC, COBGC, reimbursement manager for the department of obstetrics and gynecology at the Medical College of Wisconsin.

You can even include diagrams or photographs to better help the insurer understand the procedure. Highlight or make notes on the actual op report indicating where in the body of the op report the unlisted procedure is being described, experts say.

Compare the Procedure to an Existing Code

An insurer will decide to pay an unlisted procedure claim by reading your description of the procedure and comparing it to a similar, listed procedure with an established reimbursement value. Rather than leave it up to the insurer to determine which code is the “next closest,” you should explicitly make reference to the nearest equivalent listed procedure. After all, the treating physician is best equipped to make this determination. You should also note the specific ways that the unlisted procedure differs from the next-closest listed procedure.

Example: Your ob-gyn injected Depo-Medrol and Xylocaine into the area of the vaginal cuff that was most tender and causing dyspareunia. You should submit an unlisted-procedure code (58999, Unlisted procedure, female genital system [nonobstetrical]) and compare the work to the service 11900 (Injection, intralesional; up to and including seven lesions) represents. Contrast the service to the procedure performed. For instance, note that because the injection was not into a lesion, but into a structure, similar to a local, you could not use 11900.

Solicit Outside Advice

If the ob-gyn uses equipment and techniques that have no dedicated CPT code, you may be able to enlist the manufacturer’s aid to receive appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies.

Use caution when applying manufacturers‘ suggestions, however, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain payment.

Stick to unlisted-procedure codes when no other codes describe the procedure the physician performed. Always provide ample documentation to justify the claim’s necessity.

You should also contact your specialty societies, such as the American Congress of Obstetricians and Gynecologists (ACOG) or the Society for Maternal-Fetal Medicine (SFMF). They may have supporting descriptions to explain the procedure that you can attach to your claim, Kroening says.

Be Prepared in Advance

If the ob-gyn is repeatedly performing the same type of unlisted procedure, prepare an information file so you don’t have to reinvent the wheel every time you submit a claim. Each time a carrier denies a similar claim, you will already have an appeals packet ready to send the payer to defend your claim.