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OB services: Coding inside and outside of the package
JustCoding News: Outpatient, April 7, 2010
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by Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA
From packaged services to multiple gestations, obstetric (OB)/maternity care coding is no small challenge.
Although the 2010 CPT® Manual contains numerous codes that are part of maternity care, they are not necessarily part of the OB global billing package.
Maternity OB packages allow physician offices to bill a single CPT code for antepartum, delivery, and postpartum care. However, there are times when an OB/maternity patient receives services that do not fall within the package or complications arise that make code assignment unclear.
Identifying the CPT package codes
Note the following CPT package codes, which combine inpatient and outpatient services:
- 59400: Routine OB including antepartum, vaginal delivery, and postpartum care
- 59510: Routine OB including antepartum, cesarean-section (C-section), and postpartum
- 59610: Routine OB including antepartum, vaginal birth after C-section (VBAC), and postpartum
These package codes cover the first visit through the six-week postpartum period. Providers should bill them as a one-time procedure after delivery.
The following antepartum services are normally included in the package.
- First prenatal visit or initial evaluation, including a history and physical (H&P) exam
- Pregnancy evaluation and progress screening (i.e., subsequent or interval H&P exams, recording of weight, blood pressure, specimen handling, and routine automated chemical urinalysis)
- Care of complications during the gestational period specific to obstetrical care or that constitute the management of a chronic, stable illness (e.g., pre-eclampsia, premature labor, diabetes, epilepsy, lupus erythematous or hypertension)
Delivery services normally include:
- Admission to the hospital
- Admission history and examination
- Supervision or management of uncomplicated labor, including induction services
- Vaginal, C-section or VBAC delivery
- Delivery of placenta
- Initial evaluation and resuscitation of the newborn by the obstetrician
- Fetal scalp blood sampling and application of fetal scalp electrodes and electronic fetal monitoring
- Physician standby services
Postpartum services normally include:
- Outpatient office visits for six weeks.
- Inpatient hospital admission directly related to the pregnancy for a period of six weeks. Note: This follow-up time frame is for vaginal and C-section services. This differs from the customary zero, 10, 90 global time followed for surgical procedures.
CPT has some general coding rules that coders should follow closely when using a package code (i.e., 59400, 59410, and 59610) CPT does not specify that a physician must provide a certain number of visits to use the global OB package. Physicians commonly see patient for approximately 13 antepartum visits; however, that is not always the case. The following visit schedules are also used:
- One visit every four to five weeks up to 28 weeks
- One visit every two weeks up to 36 weeks
- One visit every week from 36 weeks until delivery
Providers should not bill separately for services bundled as part of the routine OB care visits. The following are part of the routine OB visit:
- Pap smear at first prenatal visit. Note: This applies only to the Pap smear procedure. The laboratory processing is separately identifiable and payable.
- Routine Urine Dip provided in-office (code 81002).
- Education on breast feeding, lactation and pregnancy (HCPCS level II codes S9436–S9438, S9442–S9443)
- Exercise consultation or nutrition counseling during pregnancy (HCPCS level II codes S9449–S9452, S9470)
CPT coding is not the only challenge in obstetric/maternity coding. Coders also need to pay special attention to diagnosis application. The fifth digit plays an important part of telling the story to the insurance carriers. ICD-9 codes 640–649 and 651–676 require a fifth digit. The list below are the fifth digits, which denote the specific episode of care:
- 0 – Unspecified (Note: This is rarely appropriate)
- 1 – Delivered with or without mention of antepartum condition
- 2 – Delivered with mention of postpartum complication
- 3 – Antepartum condition or complication
- 4 – Postpartum condition or complication
Coders should verify with their supervisor before using fifth digits 0, 1, or 2 in the outpatient clinic.
Coding procedures outside the package
If by chance a patient requires services outside the OB package, it is appropriate for coders to bill for them. If the patient has a complication or requires additional workup or care, coders should assign the appropriate E/M code (i.e., 99212–99215) to reflect the separately identifiable service. The diagnosis should also reflect the separately identifiable service.
The separately identifiable complications or diagnoses may not be pregnancy-related. It is common for patients to seek care for routine illnesses (e.g., colds, flu, upper respiratory infections, allergic rhinitis, headaches, muscle aches, heartburn, insomnia, etc.). There are also occasions when a physician may see a patient for an illness or injury that relates to the pregnancy (e.g., sciatic nerve impingement, back pain, abdominal pain, or even knee sprain/strain due to additional pregnancy weight).
Coders must be prepared to review, audit, and bill for E/M services that are OB/maternity related, but are not part of routine care. Use the 1995 Documentation Guidelines for Evaluation and Management Services or the 1997 Documentation Guidelines for Evaluation and Management Services to audit maternity care. Also use the CPT Manual’s single system female exam or the multi-system exam criteria as well as the Medicare Benefit Policy Manual.
Below is a listing of common OB/maternity complication diagnoses. This is not an all-inclusive list, but it gives coders an idea of diagnoses and symptoms that may place the patient in a “risk” diagnosis area:
- Pre-existing diabetes
- Gestational diabetes mellitus
- Pregnancy-induced hypertension or pre-eclampsia
- Fetal anomaly or abnormal presentation (age 36 weeks or older)
- Multiples (e.g., twins)
- Placenta previa
- HIV or abnormal screen
- Prior preterm delivery
- Prior preterm labor requiring admission (e.g., early cervical change)
- Intrauterine fetal demise
- Prior cervical or uterine surgery
- Fetal anatomic abnormality
- Abnormal fetal growth
- Preterm labor requiring admission
- Abnormal amniotic fluid
- Recurrent urinary tract infections or stones
- Advanced maternal age (i.e., 35 years or older at estimated date of conception (EDC))
- Young maternal age (younger than 16 yrs at EDC)
- Past complicated pregnancy
Billing nonpackage-related procedures in addition to E/M services requires good documentation and good communication between coders and physicians. The coder must feel confident in knowing what packages include.
Nonpackage ancillary procedures and services
Coders should report and bill for procedures not bundled with the maternity “package deal” at the time of service. Physicians may perform these procedures during routine antepartum OB visits or scheduled them as separately-identifiable visits. However, do not bill a separate E/M visit performed on the same day as a planned procedure.
Common ancillary procedures and services include the following:
- Obstetric ultrasound
- Insertion of a cervical dilator
- External cephalic version done in the clinic
- Fetal biophysical profile
- Administration of Rh immune globulin
- Fetal nonstress test (NST)
- Routine OB/maternity laboratory services such as HIV testing, Blood glucose testing, sexually transmitted disease screening, and antibody screening such as for Rubella or Hepatitis
- Blood typing and Rh factors
- Thyroid testing
Complex OB/maternity coding and billing scenarios
The OB package works well for patients who see the same physician for the entire duration of their pregnancy, delivery, and postpartum care. However, there are times when this is not the case or other complications arise. Below are some tips when billing alternative or non-traditional OB/maternity situations.
Scenario 1: The patient received antepartum care with Dr. Smith. Dr. Jones, who is in the same practice as Dr. Smith, provides the delivery. Dr. Smith does the postpartum care. In this case, coders should code and bill the entire package under the patient’s primary physician using a global maternity package code. Provide an in-office relative value unit (RVU) or payment allocation of reimbursement to the delivering physician.
Scenario 2: The patient has received antepartum care with Dr. Smith, but Dr. Dumore, who is unaffiliated with Dr. Smith’s office, provides the delivery care. Dr. Smith does the postpartum care. Coders should bill for the antepartum and postpartum services provided by Dr. Smith. Dr. Dumore should bill for a delivery only.
Scenario 3: Dr. Smith provided all services for a vaginal delivery package code. In addition, Dr. Smith performs a sterilization procedure post-vaginal delivery. Coders should code and bill the package first, then report the correct CPT code for sterilization services provided during post-vaginal delivery within the maternity stay.
Scenario 4: Dr. Smith provided all services for a C-section delivery package code. In addition, he performs a sterilization procedure immediately after the C-section. Coders should code and bill the package first, then report the correct CPT code for sterilization services provided post C-section within the maternity stay.
Scenario 5: Dr. Smith provided all services for a vaginal delivery package code. Dr. Dumore repairs a fourth degree laceration to the cervix during the delivery. Coders should code and bill for Dr. Smith’s services. Dr. Dumore will need to bill separately for the laceration repair during the delivery. Third and fourth degree laceration repairs are separately identifiable services.
With OB/maternity services, sometimes the unexpected happens (e.g., the patient miscarries or has an ectopic pregnancy). In these cases, the coder needs to audit and bill only for the antepartum services that the patient received prior to the miscarriage. Review the CPT codes and bill the appropriate E/M code for the service provided. When a physician provides care of or surgical intervention for the miscarriage or ectopic pregnancy, the coder would also need to bill for those specific services too.
And of course, there is also the challenge of coding for multiple gestations. The accepted norm for these services is to bill a global package for the first baby and a delivery only code for the second or subsequent baby(ies). Some insurance payers have specific billing requirements for these services. Most payers prefer the above method, however, some would rather the coder bill for one package code with modifier -22 (increased services) and increase the billed dollar amount by 25–40% based upon how many babies were delivered.
Coders should feel confident coding nearly any OB/maternity case. Remember to follow the CPT guidelines, correctly append diagnoses, contact insurance payers for their input, and ensure physician documentation of the antepartum, delivery and postpartum care.
Editor’s note: Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, is an independent consultant in Melba, ID. E-mail her at LORIWEBB@sarmc.org.
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