I have been told at least for Medicaid and MCO's under our FQHC we should be billing for everything as well as if they are self-pay. Most of our patient's have financial assistance so it typically isn't a problem, however when they are just self-pay I wasn't sure if there were certain things you can't bill for.
Pertaining to the outpatient/office prenatal care if a patient has Medicaid/MCO our financial assistance or are self-pay, we bill for everything. Each prenatal visit goes out as an Office visit E&M any additional services done in office (NST ultrasounds vaccines etc.) that are done in office get billed. I am not aware of any rules stating there are things that cannot bill for when the patient is self-pay.. We do also verify insurance and present prenatal agreements at the start of their prenatal care to give the patient an estimate of cost/financial responsibility.
For true self pay patients who do not qualify for our financial assistance or Medicaid we off a prompt pay discount of 20% if they pay in full.
Also I am running into an issue where two of my CMNs see the same patient in the same day. For example one midwife admitted the patient but the other midwife ended up being the one to evaluate the patient through out the afternoon/evening. Can both midwives bill for this day? If they can I know one would bill the admit but how would I bill for the second?
Are the truly admissions for monitoring or like OB holds?
I was taught by the previous office manager who did the coding when a patient presents to L&D for monitoring we just bill as an outpatient E&M code because they usually are not truly admitted although 9922* can be used for outpatient we choose to use the office codes unless it is extensive monitoring.. But if they are admitted for evaluation and monitoring you only bill for one initial code since 9922- is "per day" it can only be billed once by a provider of the exact same specialty/subspecialty who belongs to the same group practice during the stay. this is from the PDF file i am attaching.
"In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day. If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses.”
And when this does happen our CNMs seem to be in agreeance on who drops the charge to be billed.. I guess this can be billed as Split/Shared E&M but that is not something we have looked into yet..
We run into this issue more when a patient is seen in the office for a routine prenatal with Medicaid/MCO insurance and then presents to L&D for an OB hold later that day. And the prenatal visit usually gets reviewed and posted first so we do not bill for the outpatient L&D visit.
Kind of the same situation how would you bill if one midwife does most of the evaluations for the day but then a different midwife delivered that night? I wouldn't bill for anything but the delivery. for Medicaid we only bill 59409(PA medicaid rules) for the delivery and entire hospital stay. And the one that "catches the baby" get the credit.. unless it is an usually long labor and then the rule of thumb is everything prior to the last 24 hours before delivery potentially is billable outside of global. Which i have never had this happen.. so say If the patient is admitted for induction tonight 04/04/24 at 8:00pm but does not deliver until 04/06/24 at 8:00am then the initial hospital code could be billed for 04/04/24 If there is documentation to support medical necessity and patient was seen more than 24 hours prior to delivery, it could be appealed.
Lastly or at least for now.. Do you bill for extended time? So if the midwife evaluates the patient for more than the timeframe that is given for the subsequent day code do you or have you billed for extra evaluation time? we have not adopted the prolonged service codes yet.. it is something that we may be discussing in the near future for our commercial plans but as of now we do not since for Medicare/Medicaid It will not bring any additional reimbursement to our PPS rate.
I hope this information is somewhat helpful! I still am learning the ropes and am constantly researching So if anyone else who comes to the thread has input or corrections please feel free again i am no expert!
I am also attaching a PDF from a ticket i opened with the ACOG regarding CNM/MD deliveries. The CNMs had concerns on vacuum assisted deliveries due to our new incentive program. Their "submit a ticket" option is extremely helpful and saves you from going down that coding rabbit hole as i call it on google lol! There is coding and then there is FQHC coding... lol And it is nice to talk with someone else who understands that!