Maternity coding can be a challenge for coders.
(Oupatient - physician office fee for service)
by Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA
Although The 2010 CPT® Manual contains numerous codes that are part of maternity care, they are not necessarily part of the obstetric (OB) global billing package, as detailed in the 2010 CPT Manual.
Maternity OB packages allow physician offices to bill one 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 (Combines inpatient and outpatient services):
• 59400: Routine OB including antepartum, vaginal delivery, and postpartum care
• 59510: Routine OB including antepartum, C-section, and postpartum
• 59610: Routine OB including antepartum, VBAC, and postpartum
These package codes cover the first visit through the six-week post-partum period. Providers would bill them as a one-time procedure after delivery.
The following services are normally included in the package.
Antepartum services normally include:
• First prenatal visit/initial evaluation, history and physical exam.
• Pregnancy evaluation and progress screening (i.e., subsequent/interval history, physical exams, recording of weight, blood pressures, specimen handling, and routine automated chemical urinalysis).
• Care of complications during the gestational period that are either specific to obstetrical care or constitute the management of a chronic, stable illness such as 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, cesarean or V-back delivery.
• Delivery of placenta.
• Initial evaluation and resuscitation of the newborn by the obstetrician.
• Fetal scalp blood sampling. Application of fetal scalp electrodes and electronic fetal monitoring.
• Physician standby services
Postpartum services normally include:
• Outpatient office visits for a period of six weeks
• Inpatient hospital directly related to the pregnancy, for a period of six weeks.
• **Note – this follow up timeframe is followed for vaginal, and cesarean services. This differs from the “normal” -0-, 10, 90 global time that is followed for surgical procedures!
CPT has some general coding rules that need to be followed closely if you are using a package code (i.e. 59400, 59410, 59610) CPT does not specify that a certain number of visits be provided in order to use the global OB package. It is common for the physician to see patient for approximately 13 antepartum visits; however, that is not always the case. The following visit schedules are also used:
• Monthly visits up to 28 weeks
• Bi-weekly visits up to 36 weeks
• Weekly visits until delivery
Services that are considered “bundled” or part of the routine OB care visits should not be billed separately or “unbundled” out the of OB package. The following are part of the routine OB visit:
• Pap smear at first prenatal visit
o Note: this applies only to the Pap smear procedure. The lab processing is separately identifiable and payable.
• Routine Urine Dip provided in-office (code 81002)
• Breast feeding/lactation education/pregnancy education (S9436-S9438) (S9442-S9443)
• Exercise consultation or nutrition counseling during pregnancy (S9449-S9452 S9470)
CPT coding is not the only challenge in obstetric/maternity coding. Coders need to pay special attention to diagnosis application. The fifth digit plays an important part of “telling the story” to the insurance carriers on your claim. ICD-9 Codes 640-649 and 651-676 require a fifth digit. The list below denotes the “specific” episode of care:
• 0 – Unspecified (Rarely appropriate)
• 1 – Delivered with/without mention of antepartum condition
• 2 – Delivered with mention of postpartum complication
o Verify with supervisor before using these fifth digits in the outpatient clinic: 0-1-2
• 3 – Antepartum condition or complication
• 4 – Postpartum condition or complication
Coding for procedures that are not part of the package
If, by chance, the patient requires services outside the OB package, bill them. If the patient does have a complication, requiring additional workup or care, assign the appropriate E/M Code (99212-99215) to reflect that separately identifiable service. Make sure that the diagnosis also reflects the separately identifiable service.
These separately identifiable complications or diagnoses may not be pregnancy related. It is common for patients to seek care for routine illnesses (i.e., colds, flu, upper respiratory infections, allergic rhinitis, headaches, muscle aches, heartburn, insomnia, etc.). There are occasions, that a physician may see a patient for an illness or injury that relates to the pregnancy (i.e., sciatic nerve impingement, back pain, abdominal pain, or even knee sprain/strain due to the 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. As a good process, you should be familiar with auditing your maternity care with either the 95 or 97 guidelines, and using the single system female exam, or the multi-system exam criteria.
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 (older than or equal to 36 weeks)
• Multiples (i.e. 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 (35 yrs or older at EDC)
• Young maternal age (less than 16 yrs at EDC)
• Past complicated pregnancy
Billing non-package related procedures in addition to E/M services requires good physician documentation and good communication. The coder must feel confident in knowing what is/is not part of the package deals.
Non-package ancillary procedures and services.
Procedures that are NOT bundled with the maternity “package deal” should be reported and billed at the time of service. These procedures can be performed during the routine antepartum OB visit, or scheduled as a separately identifiable visit. However, if the procedure is pre-planned, DO NOT bill a separate E/M on that day. The list below gives a quick look at these services, but is not an all-inclusive list:
• Ultrasound (Obstetric)
• Insertion of a cervical dilator
• External cephalic version (done in the clinic)
• Fetal biophysical profile
• Administration of Rh immune globulin
• Fetal Non-stress Test (NST)
• Routine OB/maternity laboratory services such as HIV testing, Blood Glucose testing, STD screening, Antibody screening such as Rubella, or Hepatitis
• Blood Typing/and Rh factors
• Thyroid testing
Difficult coding and billing scenarios within an OB/Maternity practice
The OB package works well for those patients that see the same physician for the entire duration of their pregnancy, delivery, and postpartum care. However, there are situations that do not fall within that nice, tidy package. Here are some tips when billing those alternative or non-traditional OB/maternity situations.
Scenario 1: The patient has received antepartum care with Dr. Smith. Dr. Jones, who is in the same practice as Dr. Smith, provides the delivery. Dr. Smith does the post-partum care. Code and bill the entire package under the patient’s primary physician using a global maternity package code. Provide an in-office 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 not affiliated with Dr. Smith’s office, provides the delivery care. Dr. Smith does the postpartum care. 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. Code and bill the package first. Then code 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 Cesarean delivery package code. In addition, he performs a sterilization procedure immediately after the Cesarean. Code and bill the package first. Then code 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. 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, and the patient miscarries, or has an ectopic pregnancy. In these type of 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 levels of service, or E&M provided. If your physician provided care of, or surgical intervention for the miscarriage or ectopic pregnancy, the coder would also need to bill for those specific services too.
The last “big challenge” of OB/maternity coding is multiple gestations. The accepted norm for coding and billing these services is to bill a global package for the first baby, then 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. Just 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.
http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf (page 22)