Wiki OB Billing

Create Wiki
N

nklunk86

New
Messages
4
Location
Paoli, IN
Best answers
0
Needing some guidance and clarification on OB Billing. For Medicaid, repeat C-Sections, and commercial insurance that does not cover OB we have to bill individual visits. My confusion is after the 3 E&M codes then do we switch to the 59425 for 4-6 visits and then switch to 59426 for 7 on? Some ways I read it was this way and others was it all depends on how many total times they are seen. For Medicaid I only have 3 months to bill the claim for filling limits so I can't hold till the end. Can someone clarify this? Thanks
 
would be helpful to know what state you are billing in. Medicaid has different rules in different states. In TX we bill very visit individually to Medicaid with the appropriate E/M code, then bill delivery only at time of delivery, then all PP Ob care is billed under CPT 59430.They change the rules from time to time so you have to keep the website on hand to refer to. If patient has a primary insurance, you have to bill based on the rules for the primary and then after they deny , you can recode the visits per secondary Medicaid guidelines and submit the claim to them. Your local Medicaid should have a website that can provider guidance on how they require their OB claims to be billed. Once you post your state maybe someone in that location can further assist you.
 
cjorr65 said:
would be helpful to know what state you are billing in. Medicaid has different rules in different states. In TX we bill very visit individually to Medicaid with the appropriate E/M code, then bill delivery only at time of delivery, then all PP Ob care is billed under CPT 59430.They change the rules from time to time so you have to keep the website on hand to refer to. If patient has a primary insurance, you have to bill based on the rules for the primary and then after they deny , you can recode the visits per secondary Medicaid guidelines and submit the claim to them. Your local Medicaid should have a website that can provider guidance on how they require their OB claims to be billed. Once you post your state maybe someone in that location can further assist you.
Click to expand...
I'm in Indiana....though not sure that matters on the question I'm asking as far as the 59425 and 59426. My confusion is I have to bill individual for IN Medicaid, commercial insurance if they are a repeat C-section or if insurance does not cover OB care I bill them as I go but as I read it am I supposed to bill the E&M code for the first 3 visits, then 59425 for 4-6, and then 59426 for the rest? Or does it depend on the total amount of visits at the end?
 
General guidelines are to bill 59425 for all visits if patient had a total of four , five or six visits and 59426 if patient has a total of 7 or more visits. You only bill e/m for visit one through 3 if the patient only had a total of three antepartum visits. Do you bill e/m or 59425 or 59426. Does that help?
 
cjorr65 said:
General guidelines are to bill 59425 for all visits if patient had a total of four , five or six visits and 59426 if patient has a total of 7 or more visits. You only bill e/m for visit one through 3 if the patient only had a total of three antepartum visits. Do you bill e/m or 59425 or 59426. Does that help?
Click to expand...
So yes it depends on total # of visits at the end
 
In my experience, MOST carriers that require split billing want:
1) Antepartum as 59425 if 4-6 visits or 59426 if 7+ visits. If the patient had less than 4 visits, each E&M individually billed. You do not bill the first 3 E&M individually if you are billing 59425 or 59426.
2) Delivery as delivery only codes depending on type of delivery
3) Postpartum as 59430
However, this can vary and any particular payor could have different guidelines.
For example, some may want antepartum billed each E&M and not 59425/59426.
You must follow the guideline of the payor when they do not accept global maternity.
 
You must log in or register to reply here.
Top