Wiki Billing For Midwives

[rebutton23]

I am having trouble finding information on how we can bill for midwives. Our midwives go to a local hospital that we are contracted with and perform care and deliveries. The majority of the time our patients had their prenatal clinic visits with our midwives at one of our clinics. However when the patient is in the hospital for delivery there is another OBGYN clinic that, I believe is contracted with us, also sees the patient and does deliveries at the hospital along with the hospital providers and staff.

I understand the global component of billing for our midwives for the most part. We typically only bill hospital inpatient or observation care codes and delivery codes. One of the things I am having a hard time finding answers on is billing when the patient is self-pay or has Medicaid/MCO. From what I understand, if the midwife sees the patient when they are laboring and the next day they deliver, under global guidelines we do not bill the day that they were seen and just laboring. (Please correct me if I am wrong) However if they are self-pay or have Medicaid/MCO would I bill for the day that the midwife saw the patient but they were only laboring, like as a subsequent day? I guess I am having the most trouble finding the guidelines on billing for midwives when there isn't the global component.

A couple other question I have: (All based off the patient being self-pay or has Medicaid/MCO)
1. If the other OBGYN clinic or one of the hospital provider delivers the baby but our midwife saw the patient earlier in the day would we still bill for that?
2. If our midwife saw the patient and then later that day we transfer care to someone with the other OBGYN clinic or one of the hospital providers would we still bill for our midwife seeing the patient that day?

Also, if I can bill those days, what are the best diagnosis codes to use for these? (When mother is laboring)

Any help would be greatly appreciated!!!

 

[nielynco]

I am having trouble finding information on how we can bill for midwives. Our midwives go to a local hospital that we are contracted with and perform care and deliveries. The majority of the time our patients had their prenatal clinic visits with our midwives at one of our clinics. However when the patient is in the hospital for delivery there is another OBGYN clinic that, I believe is contracted with us, also sees the patient and does deliveries at the hospital along with the hospital providers and staff.

I understand the global component of billing for our midwives for the most part. We typically only bill hospital inpatient or observation care codes and delivery codes. One of the things I am having a hard time finding answers on is billing when the patient is self-pay or has Medicaid/MCO. From what I understand, if the midwife sees the patient when they are laboring and the next day they deliver, under global guidelines we do not bill the day that they were seen and just laboring. (Please correct me if I am wrong) However if they are self-pay or have Medicaid/MCO would I bill for the day that the midwife saw the patient but they were only laboring, like as a subsequent day? I guess I am having the most trouble finding the guidelines on billing for midwives when there isn't the global component.

A couple other question I have: (All based off the patient being self-pay or has Medicaid/MCO)
1. If the other OBGYN clinic or one of the hospital provider delivers the baby but our midwife saw the patient earlier in the day would we still bill for that?
2. If our midwife saw the patient and then later that day we transfer care to someone with the other OBGYN clinic or one of the hospital providers would we still bill for our midwife seeing the patient that day?

Also, if I can bill those days, what are the best diagnosis codes to use for these? (When mother is laboring)

Any help would be greatly appreciated!!!

Your question is very state specific. In this case I am assuming Iowa? The Medicaid site includes a physician billing portal (Iowa Medicaid Portal Application (IMPA)) that should be able to answer some of your questions and at Medicaid Provider Services you can find a link to each of the 3 MCO's in your state with contact information so you can ask them directly. If you are certified with each of these entities you should have been provided a link to their respective billing manuals.

 

[rebutton23]

Your question is very state specific. In this case I am assuming Iowa? The Medicaid site includes a physician billing portal (Iowa Medicaid Portal Application (IMPA)) that should be able to answer some of your questions and at Medicaid Provider Services you can find a link to each of the 3 MCO's in your state with contact information so you can ask them directly. If you are certified with each of these entities you should have been provided a link to their respective billing manuals.

Not sure if you would know the answer to this but if a Midwife is with the patient for prolonged periods of time in the hospital setting is there additional coding that should be billed I saw something about 99418 but I don't think that is what I am looking for. Or is that just all included in the E/M code? This is for non global billing.

 

[nielynco]

Not sure if you would know the answer to this but if a Midwife is with the patient for prolonged periods of time in the hospital setting is there additional coding that should be billed I saw something about 99418 but I don't think that is what I am looking for. Or is that just all included in the E/M code? This is for non global billing.

In general, if you have prolonged services and meet the CPT requirements for billing the extra time and it is adequately documented (including why the extra time was required) and as you say you are billing an E/M rather than global billing you should get paid for it. However, if the time was sitting the patient in labor and she delivers on that day, you will probably get a denial as the delivery only code also includes any E/M services provided during active labor that day. Here is what CPT had to say about using 99418:

"Code 99418 is reported in conjunction with codes 99223, 99233, 99236, 99255, 99306, and 99310 for prolonged inpatient, observation, or nursing facility services. The use of only one code to report prolonged services based on the type and place of services will simplify reporting.

The new and revised codes 99417 and 99418 also change the timing of when prolonged services reporting begins. Reporting prolonged services time will begin 15 minutes beyond the time required to report the highest-level primary E/M service. This is different than reporting guidance for deleted codes 99354 and 99355 where time began at 31 minutes of prolonged E/M services time (using the midpoint rule encompassing the first hour of prolonged services time). Similarly, code 99418 will be reported in 15-minute increments beginning 15 minutes beyond the highest-level codes for the inpatient, observation, or nursing facility E/M services. "

 

[rlfacteau]

Hi,
I am looking for clarity of billing delivery codes of midwives. Our stance has always been whoever catches the baby bills the baby, unless if the documentation supports that the provider is "in the room". Does anyone have any resources or insight into this? Some of the policies aren't very specific in FL. We are asking specifically for FL Blue, Aetna and UHC. Thanks in advance!

 

[csperoni]

Hi,
I am looking for clarity of billing delivery codes of midwives. Our stance has always been whoever catches the baby bills the baby, unless if the documentation supports that the provider is "in the room". Does anyone have any resources or insight into this? Some of the policies aren't very specific in FL. We are asking specifically for FL Blue, Aetna and UHC. Thanks in advance!

If you are billing globally, then most practices will bill under the clinician who delivers, but I do not believe this is required. Typically, you may bill under any provider who provided care to the patient. For split billing, then the clinician who delivered should definitely bill the delivery.
If you are asking about particular insurance policies, the actual payor is the best resource for that. In fact, there can be situations where one group may have a different contract with a payor than another group.

 

[nielynco]

If you are billing globally, then most practices will bill under the clinician who delivers, but I do not believe this is required. Typically, you may bill under any provider who provided care to the patient. For split billing, then the clinician who delivered should definitely bill the delivery.
If you are asking about particular insurance policies, the actual payor is the best resource for that. In fact, there can be situations where one group may have a different contract with a payor than another group.

And to add to this, why is the physician "in the room" when the midwife is delivering? If he/she is acting as a proctor, only the the delivering person who is entitled to bill independently may do so. It would be no different if there were 2 physicians present - one who observed and one who delivered. The one who delivered would bill. And the original question also does not address whether this is a group practice or a collaborative practice or whether there is some state scope of practice rule that requires supervision of the midwife. I totally agree that only the payer can clarify their rules and when those rules are vague, the coder must dig deeper and develop a knowledgeable contact with the payer's admin to get to correct interpretation.

 

[cnjacobs15]

And to add to this, why is the physician "in the room" when the midwife is delivering? If he/she is acting as a proctor, only the the delivering person who is entitled to bill independently may do so. It would be no different if there were 2 physicians present - one who observed and one who delivered. The one who delivered would bill. And the original question also does not address whether this is a group practice or a collaborative practice or whether there is some state scope of practice rule that requires supervision of the midwife. I totally agree that only the payer can clarify their rules and when those rules are vague, the coder must dig deeper and develop a knowledgeable contact with the payer's admin to get to correct interpretation.

I was asked this question by one of our CNMs recently..
"I just had a quick question on if a vacuum delivery counts towards our incentive numbers in the hospital? This question came up because I recently had three labors we treated and pushed with for several hours however, ended up with the Doctor needing to assist with the delivery via vacuum – so then they would be documented as the delivering clinician."
This would be for CNMs and MDs within the same group/tax id. When i took over our OBGYN delivery and surgery coding i was taught if the MD assists hands on in the delivery the delivery goes to them.. is that correct? Is there a way to bill for the CNMs work? Just trying to gather as much info as possible to present to them!

Thank you!

 

[nielynco]

I was asked this question by one of our CNMs recently..
"I just had a quick question on if a vacuum delivery counts towards our incentive numbers in the hospital? This question came up because I recently had three labors we treated and pushed with for several hours however, ended up with the Doctor needing to assist with the delivery via vacuum – so then they would be documented as the delivering clinician."
This would be for CNMs and MDs within the same group/tax id. When i took over our OBGYN delivery and surgery coding i was taught if the MD assists hands on in the delivery the delivery goes to them.. is that correct? Is there a way to bill for the CNMs work? Just trying to gather as much info as possible to present to them!

Thank you!

In my opinion, if the MD assists, he/she should be billing as a assistant, not the delivering practitioner. If the physician is instead brought in to perform the actual delivery without the CNM participating other than offering a helping hand, the physician should get credit for the delivery. Again, ask yourself how this would be handled if there were 2 physicians involved in this situation and not a CNM/MD combination - they should be treated in the same manner.