Wiki 59430 Post Partem with E&M


Kapolei, HI
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Can we report a 59430 post partem with an E/M? Why or why not? Please site source of information.

Patient came in 4 weeks after vaginal delivery. Provider did complete post partem but also found a lump in breast. Ordered ultra sound for lump in breast. Now wants a 59430 with 99212 mod 25.

I was told that insurance will only pay the higher of the two if we submit both and they may deny both so it would be better to code just the 59430. I just need help with showing my provider why and giving her some sort of source of info: insurance, CMS guidelines etc.
That's an interesting question. I've never had a provider try billing a separate E&M, but I can understand the reasoning behind it. CCI edits will let you bill the 2 codes together with a modifier on the 99212 (per my SuperCoder CCI edits checker tool). I can't find any OB-GYN Coding Alert articles addressing this kind of situation. I'm thinking that if your clinician provided an E&M service totally unrelated to the postpartum condition, and s/he has good documentation to support the 2 separate services, then I'd try billing the 2 together. Unless the payer has specific policy stating EVERYTHING done at the time of a pp visit is included in the 59430, I'd even appeal any denial received on the 99212.

I'm just thinking out loud without anyone to bounce my opinion off of. Somebody else may have an argument against billing the 2 together that I'm not thinking of right at this minute.

Becky, CPC
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I'm assuming your physician didn't deliver or provide antepartum care, as the global care, delivery and pp care codes would be more appropriate. IF your dr didn't deliver and provide antepartum care, 25 would be appropriate to bill with the 99212 on the same claim. Anticipate a denial, however, if your physician documents their office visit in a detailed fashion, this is absolutely appealable.

If, however, global care was provided and coded not including pp care for whatever reason, you would also need a 24 mod to exclude the 99212 from the global ob services.

Hope it all works out for you!