Wednesday, December 5, 2012

Fetal NST Testing...Documentation

The information today revolves around the Fetal Non Stress Test (FNST or NST).   The FNST test is denoted by CPT code 59025.  The NST is a basic standard of care in an OB/GYN practice or in an OB/GYN hospitalist (emergency practice).  The ultimate goal of antepartum fetal surveillance is preventing fetal death. The definition of this test is:The monitoring of the fetal heart rate in response to fetal movement. 

The FNST is within the scope of the OB/GYN physician or provider of care, and  is regarded as a very routine part of the practice.  Many providers as their standard of care  “always” run a FNST or at least do dopplers on the fetus to ensure that fetal activity is normal and not compromised by maternal complications.  However, this standard of practice does not mean that the FNST’s importance to the care of the patient be minimized.  In fact, this is probably one of the single most non-invasive tests we can perform to ensure maternal and fetal well being, when care is given in an emergent or acute care setting.

The code 59025 is considered a “global” code when performed in the office setting, as normally the office owns the equipment and the provider does an interpretation of the test findings.  If you are performing this test in an office setting there must be very "definitive" medical necessity for this to be billed as a separately identifiable test - outside of the globall antepartum package.   It is not medically necessary to run this test simply because the patient comes in for their regularly scheduled OB/antepartum visit.   It would be appropriate to run the test if there is a documented "reason" such as decreased fetal movement, maternal diabetes, maternal hypertension,  or symptoms such as pain, pressure, bleeding, spotting etc.

 When this testing is performed in the hospital facility, the hospital will be billing the test (59025-TC) as the  technical component only.  You, as the OB/GYN hospitalist, need to bill the interpretation of this test as denoted by code 59025-26.  This test will be billed separate to your Evaluation and Management of the patient.  (eg  codes 99201-99215 etc)

As we have discussed before, medical necessity is the driver for all testing.  Documentation is the key to supporting the medical necessity of any testing provided.  Good documentation will “seal the deal” for insurers (3rd party payers) to pay for FNST testing.  Your documentation for this testing should include a good solid diagnosis which can be a definitive dx such as IUGR, or signs and/or symptoms such as spotting, bleeding, abdominal pain/pressure etc.

Your role, as the provider/physician is the interpretation of the test results.  Most often, the nursing/assistive staff will probably be the ones to set up and run the test over the course of the patient’s stay in the office or facility.  If you have a patient that is pregnant with a multiple gestation, You can code and bill for each fetus.   

If you are performing a multiple FNST, you can only for one (1) technical component, (or global)  but you can bill for a separately interpretation each baby/fetus’s reading on the printouts 

If you are in an office setting to bill for a multiple it should look like this: 
59025 (Global) for Baby A 
59025-26-51-59  (Interp only) for Baby B 

If you are billing for a facility only  (regardless of how many babies are on board)

If you are billing for the Professional interpretation only 
59025-26 for Baby A
59025-26-51-59  Baby B

When interpreting these results best practices include the following for documentation of the FNST.   The interpretation of the fetal heart rate tracing should follow a systematic approach.  Third Party Payers require documentation/interpretation of all FNST’s to be noted and signed by the provider.
The bullets below denote what needs to be included for an interpretation of the FNST:

         Clinical Indication: (i.e. Decreased Fetal Movement, IUGR, etc..)
  • Interpretation:  Fetal Heart Tones (FHT) show a baseline of 130 with 10x10 accelerations and moderate viariability  Reactive with no decelerations
  • Time noted: (Best practices):  patient was monitored for “x” minutes, over the course of the stay. 
  • Signed/Authenticated by: Jose Hero, MD

Note: If the NST service is a ‘global service”  the bill date will be the same as the date performed.  If the interpretation of the test is performed on a different date than the NST test itself, then interpretation only should be billed on the date the ‘interpretation was performed’

Beware of “bundled” services with the code 59025:  CPT includes the FNST as part of the code set  definition for Ultrasound codes 76815, 76818, 76819.  If the ultrasound is performed and also the FNST, do not report them separately.

Text based Documentation:
Ms. L is a 35-year-old gravida 5, para 3, white female patient of Dr. Hero at 36-4/7 weeks' gestation who presents complaining of uterine contractions.  They are anywhere from 4-10 minutes apart and are mild to moderate.  She denies any leaking fluid or ruptured membranes or bleeding.  She has had no problems with this pregnancy except that her blood pressure has been running somewhat high throughout her pregnancy with systolics in the 140s on numerous occasions.

VITAL SIGNS:  Afebrile, vital signs stable.
GENERAL:  The patient is a well-developed, well-nourished, female in no acute distress.
ABDOMEN:  Soft.  Uterine contractions are present about every 4-6 minutes.  
Fetal heart tones show moderate variability, 15 x 15 accelerations and no decelerations with a baseline of 145 Testing was based over 45 minutes on the fetal monitor. .
PELVIC:  Cervix is very posterior, -2 station, 50% and tight 2 cm, unchanged after walking for an hour.

ASSESSMENT: False labor in a multiparous patient at 36-4/7 weeks' gestation. Fetal status reassuring

PLAN:  Patient was given labor instructions.  She will be calling Dr. Hero's office later in the day to get a refill on her Norco and Fioricet.  She does not want anything else from us now.

Last but not least -  If it wasn’t documented, it wasn’t done! Clear and concise documentation works well.  You don’t have to dictate volumes and pages to support your coding and billing.