Sunday, January 3, 2016

Q&A part 2 (Unbundling the global pregnancy package)

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. “

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 or you can also find current coding information on her blog site:  


[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.

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