Q&A – from Webinar (Part 2)
2.1 Q: Is
billing an e/m along with a 0501F code on an initial OB appointment when the
confirmation of pregnancy is done at the same appointment allowed? If not
what ways other than servicing the patient at two separate appointments can we
be reimbursed for both the initial (global) and the confirmatory appointment?
2.1.1 Q .When a new patient comes to the office with
symptoms of pregnancy but doesn't know that she's pregnant and a test
determines that she is pregnant does that 1st visit billable or is it part of
the global package?
2.1/2.1.1 A: As per the American Congress of
Obstetricians and Gynecologists (ACOG) guidelines in which most OB practices try to
follow, ACOG presented information (see below) as their recommendation when
reporting the confirmation of the first pregnancy visit
“The initial OB visit may be reported as an E/M service under certain
conditions. Even if the patient has
taken a home pregnancy test, the initial visit may still be billed as an E/M
service as you will be officially confirming the pregnancy.
When coding for the “initial ob visit”, there are a few things that
have to be taken into consideration.
First you have to determine if the patient is there for a confirmation of pregnancy or if the
pregnancy has already been confirmed. The second thing that needs to be determined
is if the OB record has been initiated.
Once this has been established you can determine how the visit should be
reported.
“http://www.acog.org/About-ACOG/ACOG-Departments/Coding/Reporting-the-Confirmation-of-Pregnancy-Visit
The above information was taken directly from the ACOG
web site. However, in my opinion
regarding the billing of the E&M along with the designation of the Category
II Code 0501F for the initial OB appointment.
I consider the “OB start antenatal”
at the time the OB flow sheet is initiated, and the physician is
performing the comprehensive intake and evaluation process for a new OB
patient. This process is certainly
separately identifiable from simply “confirming” the pregnancy. A pregnancy confirmation visit would
normally be a very short and quick E&M visit, then the patient scheduled at
a later date to begin the OB intake and flow sheet process which would include
the comprehensive history, exam and plan of care for the current pregnancy.
In my opinion, I would have it clearly defined that the
OB “confirmation” of pregnancy is documented as clearly defined/separately identifiable
from the “Ob start antenatal” if your office practice chooses to bill for the
E&M, and begin the evaluation/OB flow sheet at the same encounter.
____________________________________________________________________________________
2.2 Q: On a delivery account, would you code RH
immunization on the mother's chart if she is given Rhogam during the pregnancy
but not at the delivery because baby is also RH negative?
2.2 A: A couple of
years back I looked at this issue and from a clinical standpoint, the Rh factor
of positive and negative can lead to problems between a mother and the
developing fetus. It is commonly
referred to as mother-fetus incompatibility, and occurs when the mother is
Rh-(negative) and the fetus is Rh+(positive).
To help prevent these complications during pregnancy, physicians routinely order the pregnant
patient to undergo testing to determine the Rh and ABO blood typing. Once this has been completed, the physician
will then determine if having the patient receive the Rho(D) immune globulin.
As for the clinical documentation to be recorded in the
chart, if the physician suspects and initiates the RH immunization during the
pregnancy it is assumed that the patient and fetus have the
incompatibility. However, if this is not
the case at the time of delivery, then the provider should notate this finding
at that time. However, according to the
American Congress of Obstetricians and Gynecologists (ACOG) they have developed
a standard guideline of re-administration of the Rho(D) immune globulin product
These standards are:
·
The first dose of Rho(D) immune globulin is to
be given at 28 weeks’ gestation (earlier if there’s been an invasive event),
·
Followed by a postpartum dose given within 72
hours of delivery.
_____________________________________________________________________________________
2.3 Q: With the prenatal visits and the delivery as
separate from the OB package you would always append the -59 to the delivery?
My understanding is the -59 is used only for procedure to procedure?
2.3 A: The
modifier 59 should not be appended to the code(s) when an “unbundled” delivery
is billed for at the same time the charges for the antepartum services are
billed. In addition, these two services should be billed on two
separate claims, identifying the first claim as antepartum services only
denoting the span dates you saw the patient.
The billing of the delivery should then be on a separate claim showing
the “delivery only” as unbundled and dated as the actual date of delivery.
On your claim information note line, you should denote
“antepartum care only” and the usage of the codes 59425/59426 or E&M visits
denoting the antepartum care. Within the defined parameters of CPT’s
definition of modifier 59 there is critical verbiage that I have highlighted
below that refers to those services “not ordinarily encountered or performed on
the same day by the same individual. The
antepartum care and the delivery would not fulfill this parameter for modifier
59.
Rationale: The 2015 CPT Manual defines modifier 59 as
follows:
“Distinct Procedural Service:
Under certain circumstances, it may be necessary to
indicate that a procedure or
service was distinct or independent from other non-E/M
services performed on the same
day. Modifier 59 is used to identify
procedures/services, other than
E/M services, that are not normally reported
together, but are appropriate
under the circumstances.
Documentation must support a
different session, different procedure or surgery, different site or organ
system, separate incision/excision, separate lesion, or separate injury (or
area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the Same
individual. However, when another already established modifier
is appropriate, it should be used rather
than modifier 59. Only if no more descriptive modifier is available, and the
use of modifier 59 best explains the circumstances, should modifier 59 be used.
Note: Modifier 59 should not be
appended to an E/M service. To report a separate and distinct E/M service with
a non-E/M service performed on the same date, see modifier 25.”
_____________________________________________________________________________________
2.4 Q: Are we able
to bill an E&M visit if a pap was performed at the post-partum appointment?
2.4 A: In a normal
post-partum service visit(s) as part of the global package, a pap smear is commonly
performed as ‘routine’ testing during
the post-partum period, and the “cervical pap scraping” or procurement
procedure performed by the physician/midwife is bundled into the postpartum
visit. However, the pap-test itself (e.g.
88175) would be billable.
If the “Pap scraping” is being performed during the
postpartum period is a part of a separately identifiable workup for a problem
(not pregnancy/postpartum related) then
an E&M would be billable and the procurement of the scraping is bundled
into the E&M service. A modifier 24
would also need appended as an E&M service provided during a post-op time
frame.
Rationale: According
to the postpartum care guidelines put forth by CPT and ACOG this is what is
normally provided during the postpartum period[1]
at the time of the post-partum pelvic exam, that would be when the pap smear
scraping/procurement would take place.
·
Postpartum visit ( On or between 21 days and 56
days after delivery)
o Pelvic exam and /or weight,
BP, breast, and abdomen exam.
o Screen for postpartum
depression. Refer for intervention if indicated.
o Screen for domestic violence.
o Discuss sexual activity and
contraception with an emphasis on the benefits of long-acting reversible and/or
non-reversible contraception.
o Review nutrition and
exercise.
o Discuss method of feeding
(breast or bottle).
___________________________________________________________________________________
2.5 Q: If the pap is performed in the middle of the
pregnancy is it billable?
2.5 A: If a pap smear is performed during the middle of
the pregnancy, it would be billable. The
need for a pap smear would be a medically necessary and separately identifiable
diagnosis. The Pap smear is normally
considered a routine part of pre-natal care. If a patient does have an abnormal
Pap result during pregnancy, the physician or provider will determine at that
time, what (if any) treatment or
procedures can be safely performed based upon the specific diagnosis or
reason. The physician or provider may
delay treatment until after delivery. In this instance, those E&M visits would
be billed as a separately identifiable service outside the global package, the
procurement of the pap itself is bundled into the E&M and the pap test
itself (e.g. 88175) would also be billed with the diagnosis appended.
____________________________________________________________________________________
2.6 Q: In the new
ICD-10 code set, when do we use the incidental pregnancy code Z33.1?
2.6 A: In the
guidelines from ICD-10cm, the codes from chapter 15 and sequencing priority
state:
“ Obstetric cases require codes from chapter 15, codes in the range
O00-O9A, Pregnancy, Childbirth, and the Puerperium. Chapter 15 codes have
sequencing priority over codes from other chapters. Additional codes from other
chapters may be used in conjunction with chapter 15 codes to further specify
conditions. Should the provider document that the pregnancy is incidental to
the encounter, then code Z33.1, Pregnant state, incidental, should be used in
place of any chapter 15 codes. It is
the provider’s responsibility to state that the condition being treated is not
affecting the pregnancy.” 2
What this means, is if the patient presents with a
separately identifiable diagnosis that is not related to the pregnancy but yet
the patient is pregnant, the code Z33.1 should be appended to the claim. A good example of this is; Patient is 23
weeks and 0/7 days pregnant, … and has been diagnosed with an unspecified
sprain of unspecified ligament of ankle, initial encounter. This would be coded as: S93.401A Initial
encounter
Z33.1 pregnant state incidental
Z3A.23 week’s gestation of pregnancy
2.7 Q: We were told
we could not bill for cervical dilation that it is "bundled" into the
antepartum. How can we get this paid???
2.7 A: At this time, the CPT code 59200 states
"insertion of cervical dilator"
is considered a separate procedure.
However, according to ACOG, If the service is performed one day (24 hrs)
or more prior to a delivery, it can be reported separately. ACOG also states to use modifier 59 appended
to the code 59200 on your claim. As a
coder, you will need to confirm if the cervical dilation service was performed
on the SAME DAY as a delivery, it would be considered part of the global
package and not separately reported.
The only other way this service would be billable, is if a
non-global physician provided the procedure for code 59200. In this instance, the non-global (not in the
same office, or shares the same tax ID # as the global provider) physician
would be able to charge for the cervical dilation. 3
__________________________________________________________________________________
2.8 Q: We have had
cases where our MD has been called to the labor area (and sometimes even the
emergency room) , as the patient came in
thinking she was in labor.
However, labor was ruled out.
Sometimes the patient had just Braxton hicks contractions which we have
a good diagnosis to use. Other times,
they thought they were leaking. We were
wondering what type of diagnosis can be used for those times patient "thought"
they were leaking but really weren’t. now that ICD-10 has become the new codeset?
2.8 A: That is always
a tough call, but the patient did arrive to an "emergency" type
area. I have used code O99.89 -- Other
specified diseases and conditions complicating pregnancy, childbirth and the
puerperium, and I have also used O47.XX False labor section within ICD-10 if
the provider documents clearly “false labor”.
Good documentation from the provider is essential in getting a good
diagnosis to support the medical necessity for the patient to be seen and
billed for the separately identifiable E&M visit within the global care of
the pregnancy. If the provider only
documents signs and symptoms, then as a coder you will only code for those that
are noted.
In addition, when filing
the claim to the insurance carrier,
include claim notes to also support your codes and diagnoses (eg vaginal leaking, pelvic pressure, etc..) This addition of information added to the
claim helps clarify to the erd party payer/carrier exactly "what" the
other disease, symptom or condition is.
Don’t forget to add the Z3A.XX weeks of gestation code to provide
information to the carrier how far along in the pregnancy the patient is.
________________________________________________________________________________
Lori-Lynne A. Webb, CPC, CCS-P,
CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and
Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy
specialist, with over 20 years of experience.
Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist
Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general
surgical coding. She can be reached via
e-mail at webbservices.lori@gmail.com
or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
.
[1]
American College of Obstetricians and Gynecologists (ACOG) Guidelines for
Perinatal Care, Sixth Edition October 2007.
2 ICD-10-CM Official Guidelines for Coding and
Reporting FY 2016 Page 51 of 115
3 CPT®
is registered trademark of the American Medical Association.
http://www.ama-assn.org/
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