Primary Care Coding Alert

Question: A family practitioner (FP) has provided obstetric care to a patient, including the initial ob visit and 10 prenatal visits. The patient presented at the hospital full-term and expecting a normal vaginal delivery. She was in labor all afternoon, and the FP was apprised of her condition by telephone. The physician arrived at the hospital and was with the patient for two hours trying to get the baby to descend. When the baby failed to descend, he called an obstetrician to perform a C-section, which the FP attended. How do we bill for the physicians time during labor and delivery, as well as the prenatal and postpartum care, when we cant use the global care code (59400)?

Illinois Subscriber

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Answer: There is no black-and-white answer for this question. Although there may be more than one way to code pregnancy care without delivery, knowing how to correctly code a situation does not guarantee payer agreement with the method you choose.

In general, when a baby is delivered by a physician other than the attending physician and the other physician intends to bill for that delivery, the attending can do one of two things depending on what the payer will accept. Option one is to code for global care (59400, routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) but add modifier -52 (reduced services) to indicate that a portion of the service was not performed. This method would work with either vaginal delivery or cesarean. However, since another physician will be billing for the delivery only, the attending physician should reduce his or her fee by the amount he or she would usually charge for performing only a delivery.

Option two would involve coding 59426 (antepartum care only; 7 or more visits) for the prenatal visits, billing for the hospital inpatient visits from the 99221-99239 section of CPT (both the initial care and any subsequent care), and billing for postpartum care (59430).

If the family practice physician is present during the cesarean delivery but does not participate in the surgery, only direct patient care for that calendar day can be billed. If there was participation in the surgery, there is the potential to bill for assistant-at-surgery services, reporting the procedure code with the -80 modifier (assistant surgeon). Note, however, that many insurers do not reimburse an assistant at cesarean unless the documentation clearly shows a complication during the surgery. In either option, the obstetrician who performed the cesarean will bill the appropriate delivery-only code.

I recommend option two because it is [...]