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assistant for c-section

  1. #1
    Default assistant for c-section
    Medical Coding Books
    I code for a general surgery group, therefore I am hoping for some help with this OBGYN question. To make a long story short, one of my surgeons assisted an OBGYN with an emergency C-section. The OBGYN who performed the C-section was covering for the patients regular physician (The two OBGYN's are in the same group). When I called the billing office of that particular OBGYN to ask for the correct codes, so that I could bill for the assitant fee, the billing secretary told me that I could not charge for the assitant fee because she already had. When I asked her to explain - she said: the surgeon fee was charged out under the patients actual doctor, and the assitant was charged out under the name of the doctor that was covering (the doc who actually performed the surgery). So, to be sure I understood correctly, I repeated to her: you charged out a surgical fee under the name of a doctor who was not even present in the O.R., based on the fact that that doctor is the patients primary OBGYN - and you charged an assistant fee for a doctor who performed the primary portion of the procedure?? To which she responded - "that is how this practice does it."

    This makes no sense to me......however, again, I do not do any OBGYN billing - therefore I'd like some help with this issue. I'm not understanding why my doctor, who was the ligitimate assitant - cannot charge for the service??

    Help please!
    Last edited by psantilli; 10-14-2011 at 12:58 PM.

  2. Default
    Seems to me the Dr who delivered the baby from the other practice should charge for the delivery only, breaking out the antepartum to the Dr he was covering for and your Dr should bill for the delivery only assist.

  3. #3
    Wow, that doesn't make sense to me. We bill only for the services our providers perform.

  4. #4
    This is not the correct way to do that. However, I think a lot of providers feel that when they share call, they can bill time for time. Meaning that the covering provider doesn't bill for anything and the OB that is the patients provider still bills the global. This is not the correct way to do it, but I have heard several providers say that is how they do it.

  5. #5
    Portland Rose City Oregon Chapter
    In our office, our providers cover each other for deliveries all of the time. When this happens, the doctor that performed the delivery does not get to bill out for the service as we bill out under the patient's regular provider. The doctor who performed the delivery is credited on the administrative side. If an outside office assists us, then they bill out for that service.

    The doctors office that your physician assisted is incorrect in what they did. You should be billing for the assistant fee. You may want to contact the administrator for that office and discuss and make her aware that this is happening. They may not be aware that their biller is not appropriately billing for their office. It could in turn cause an audit for their company. You may also want to make your doctor's aware. Alot of physicians sometimes do courtesy deliveries for one another but in this case, your physician should be reimbursed appropriately. Depending on what kind of relationships your providers have with the other office, they may choose not to take cases on with them.

    If I were you, I would then submit a claim for this assist and send the operative report along with it showing your doctor did in fact assist. Use the appropriate C-section only code (59514) with modifier 80 along with what codes you deem proper. Make sure you are billing with the most appropriate pregnancy delivered codes and the outcome of the delivery (V27.0). The insurance company may deny your claim but then you can contact them and let them know the situation. They in turn will request back any money paid to the other office for the assistant and then pay you.

    I hope all of this information helps you and good luck. If you ever have any questions, please feel free to email me.
    Amber Ruiz, CPC
    Women's Health Today

  6. #6
    Tacoma, WA
    I agree with Amber. I worked in OB/Gyn for 20+ years. When docs in the same practice cover for each other, we would bill under the name of the patient's main provider. But whomever actually assisted at the C-section would be the one to bill for that service. A call situation within the same practice is one thing...but taking money away from someone who provided services outside your practice is potentially fraudulent.

    As the surgeon's office, I would bill the assistant surgeon charges with the appropriate codes and send the documentation showing that the surgeon was the assistant. This will result in a take-back on the other provider's claim and might spark an investigation into their billing practices!
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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