2027 Prenatal visits vs. problem-oriented visits

[akingdon]

For the new 2027 OB/GYN antepartum coding guidelines, has anyone heard or have a reputable reference on how prenatal visits and problem visits are to be billed out? Most payers won't accept/pay for 2 E&Ms from the same provider/group practice on the same DOS/POS.

If the patient has a separately identifiable problem that is addressed during the visit:
-do we combine the managed MDM elements and treat it as one continuous service, billing only 1 comprehensive E&M?
-do we use an E&M for the prenatal visit and another E&M for the problem visit with a 24 or 25 modifier for the unrelated pregnancy issues?

What if the problem is related to the pregnancy?
-do we combine the managed MDM elements and treat it as one continuous service, billing only 1 comprehensive E&M?
-do we use an E&M for the prenatal visit and another E&M for the problem visit with a 24 or 25 modifier?

 

[nielynco]

For the new 2027 OB/GYN antepartum coding guidelines, has anyone heard or have a reputable reference on how prenatal visits and problem visits are to be billed out? Most payers won't accept/pay for 2 E&Ms from the same provider/group practice on the same DOS/POS.

If the patient has a separately identifiable problem that is addressed during the visit:
-do we combine the managed MDM elements and treat it as one continuous service, billing only 1 comprehensive E&M?
-do we use an E&M for the prenatal visit and another E&M for the problem visit with a 24 or 25 modifier for the unrelated pregnancy issues?

What if the problem is related to the pregnancy?
-do we combine the managed MDM elements and treat it as one continuous service, billing only 1 comprehensive E&M?
-do we use an E&M for the prenatal visit and another E&M for the problem visit with a 24 or 25 modifier?

If the problem is related to pregnancy, you would combine all the work and report only 1 E/M. If is it totally unrelated to pregnancy (ie, she has the flu or a bad cold), I can imagine most payers will also want it all rolled into the same E/M as it was addressed at the same visit. But this is a question you should be submitting to ACOG and the AMA CPT Editorial Panel for clarification on. Or you could address it with your payers (who may or may not respond). If it were two different visits on the same date for different reasons, then clearly you would bill 2 visits. But when all the care is rendered at the same visit, only the MDM or time spent increases so one E/M would capture it. Your diagnosis codes at the time of the visit (along with good documentation) should support a higher level of service at the time of the visit. If not, the payer may decide to have you split them out with a modifier (and one they have created most likely) to separate out the ob care from non-ob care. We are all on the same learning curve here so I expect the implementation of the new way of coding which is intended to makes things easier, will probably not go as smoothly as planned unless we all start communicating our concerns directly with payers and the ACOG.

diagnosis codes, diagnosis coding