Modifier -TH interpretations wanted!!!

[csperoni]

Regarding claim modifier -TH for antepartum/postpartum visits billable as E/M.
TH - Obstetrical treatment/services, prenatal or postpartum
A provider appends modifier TH when a female patient receives medical care for problems related to her pregnancy and following the birth of the child.
Explanation
This modifier indicates that a female patient receives medical care for problems related to her pregnancy and following the birth of the child.
The provider may render requisite treatment for the various aspects of pregnancy, including monitoring the health of the mother and providing medical support for the recovery of the mother following a cesarean or normal delivery.

I personally am interpreting the above from a coding perspective that -TH is appropriate on ANY E/M maternity visit, whether routine or non-routine (like for MFM specialists for example). We are in the process of an automated build for any E/M with a maternity diagnosis by an ob provider to auto-append -TH. This avoids the problem of relying exclusively on the provider to remember to add -TH on all the maternity visits.
However, Aetna has come out with a policy stating the opposite. "Non-routine prenatal and postpartum E&M office visits shouldn’t be submitted with modifier TH...."

I would love to hear opinions of anyone and everyone about the interpretation of when -TH is appropriate. And what steps you are taking within your offices and organizations.

 

[nielynco]

Regarding claim modifier -TH for antepartum/postpartum visits billable as E/M.
TH - Obstetrical treatment/services, prenatal or postpartum
A provider appends modifier TH when a female patient receives medical care for problems related to her pregnancy and following the birth of the child.
Explanation
This modifier indicates that a female patient receives medical care for problems related to her pregnancy and following the birth of the child.
The provider may render requisite treatment for the various aspects of pregnancy, including monitoring the health of the mother and providing medical support for the recovery of the mother following a cesarean or normal delivery.

I personally am interpreting the above from a coding perspective that -TH is appropriate on ANY E/M maternity visit, whether routine or non-routine (like for MFM specialists for example). We are in the process of an automated build for any E/M with a maternity diagnosis by an ob provider to auto-append -TH. This avoids the problem of relying exclusively on the provider to remember to add -TH on all the maternity visits.
However, Aetna has come out with a policy stating the opposite. "Non-routine prenatal and postpartum E&M office visits shouldn’t be submitted with modifier TH...."

I would love to hear opinions of anyone and everyone about the interpretation of when -TH is appropriate. And what steps you are taking within your offices and organizations.

Per the AMA: Beginning Jan. 1, 2027, antepartum and postpartum care will be reported per encounter using the appropriate E/M code. The AMA has recommended the use of HCPCS modifier TH so that antepartum and postpartum care is not subject to co-insurance, co-pays or deductibles, consistent with Section 1001 of the Patient Protection and Affordable Care Act (42 U.S.C. § 300gg-13). Pregnancy-related encounters may also be identified using the appropriate ICD-10-CM pregnancy diagnosis codes.

As this is the reason for use of this modifier, I would also interpret its use as you have. But as we know each payer decides their own interpretation and if this is in writing, you will have to make exceptions to the rule for the claim to get paid. I would auto use the TH and then have the claim reviewed for the patients who have Aetna to remove it before submission. But I would also check on the coinsurance, etc. requirement when it is not used versus when it is used for Aetna and challenge if the law is being broken by this policy.

diagnosis codes, diagnosis coding