009.521 (supervision elderly pregnancy, 1st trimester) and Z3A.10 (10 week) and 036.8391 (unable to hear heart tones) - What modifiers do I need to use and which DX do I use to have the OV and the US paid? Thank you - VERY new to OB billing.
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Wiki 99203 76801
- Thread starter dsnead@obgyn-alliance.com
- Start date
nielynco
Expert
In billing for the ultrasound you assign the code which is the reason for doing it. In this case, unable to hear heart tones. But I would report O36.80 instead (fetal viability) as the code O36.8391 implies there is a heart beat but it is abnormal. O36.80 on the other hand states you are doing it to see if there is a viable pregnancy (especially at 10 weeks). You secondary code on the ultrasound will be Z3!.10. I would not report O09.521 as the first listed diagnosis in support of the the ultrasound.
If you are not providing all of her OB care (eg, your provider is perhaps a MFM specialist billing just for these services) or your payer requires that each visit be billed separately, or your provider has not already started OB care for this patient and this is her first visit and she is seeing him for a problem and not routine OB care for that very first visit, you can bill both the E/M and the ultrasound, but no modifier is required. If not, you bill only the ultrasound code. If she had already established care with your provider and this is visit 2, you are in the global period from the payer perspective and although you can submit the code for a problem E/M at this visit, you will most likely get a denial. But that is fine, because you will have filed timely and after delivery or the end of the pregnancy you can go back and appeal the denial for the problem. O09.521 does not support the ultrasound, but may be the primary reason for the office visit. Remember that each service billed must be supported by the most important reason it was performed listed first which means that a claim submitted with multiple services may have different ICD10 codes assigned on each line item.
Thank you. This is a new patient to our practice - a OBGYN. At a first NOB appointment, there was no heart tone when one should have been determined by that date. So an US was performed. The physician has the 3 DX codes and the 2 procedure codes. To be sure - you're saying, OV can be tied to establishing care/pregnancy (Z3A.10) and the US tied to 036.80 (fetal viability) - and no modifier. Correct?
If not - I'm confused. I'm sorry. I do want to understand the nuance.
Side question I was about to post after looking through the threads/history - can you answer this unrelated question?
Pregnant patient establishes pregnancy care in another office/another provider - same insurance throughout pregnancy. She transfers to our office - new provider/new office. The initial visit should be to establish care with our office so we can do the intake - E&M 99203 with Z76.89 (encounter to establish care with a new provider). However, she would be in the global and the insurance would have paid the original provider/office the E&M code to establish the pregnancy. We would NOT code to establish the pregnancy, but to establish the patient only. Is this allowed since she is in the global period? Some pay - some don't. Any nuance about the "why some do and some don't" would be greatly appreciated.
If not - I'm confused. I'm sorry. I do want to understand the nuance.
Side question I was about to post after looking through the threads/history - can you answer this unrelated question?
Pregnant patient establishes pregnancy care in another office/another provider - same insurance throughout pregnancy. She transfers to our office - new provider/new office. The initial visit should be to establish care with our office so we can do the intake - E&M 99203 with Z76.89 (encounter to establish care with a new provider). However, she would be in the global and the insurance would have paid the original provider/office the E&M code to establish the pregnancy. We would NOT code to establish the pregnancy, but to establish the patient only. Is this allowed since she is in the global period? Some pay - some don't. Any nuance about the "why some do and some don't" would be greatly appreciated.
nielynco
Expert
As she was new and she was establishing/starting ob care you would not bill the E/M service unless the ultrasound showed no heartbeat in which case there is no viable pregnancy. If she is continuing care with the practice (because the ultrasound showed a heart beat), you can try and bill the E/M service, but my experience tells me you will get a denial for the E/M.
And you are actually getting paid for a new patient visit with Z76.89? Can you explain what type medically necessary services you are providing the patient at this visit to establish care? I think you should check on that as if she is pregnant and new to your practice, the first visit starts ob care if you initiate anything related to pregnancy care and I have never found a payer who is willing to pay for a meet and greet visit. If she is new and she is coming in to confirm pregnancy, the level of visit should be low and you should be confirming pregnancy only - any additional work related to pregnancy care means you have started the OB package. If she is transferring care you bill only the services you provide using the global antepartum code that represents the total number of visits before delivery (and this code includes one new patient visit), then the delivery with postpartum code that applies.