OB Coding for a "missed" delivery - what is right? wrong? what do I do?

This seems to be at the forefront of a lot of OB offices. In Idaho (where I reside) these are the scenario's that we utilize the most. However, your facility or practice, may choose something different. There is nothing from ACOG stating what is "right". I have come up with this bulleted list, to view your options. Again, it would depend on your physician practice and/or facility (if MD's are salaried vs/private) Thanks L : ) There are a number of scenario's, but I have reviewed what has been most common that yy readers have inquired aboaut. The "most appropriate" way to do these I've compiled below. (eg that insurance carriers like to see) Scenario A A)If you are the attending(Global OB): Bill the global code (59400) with a mod -52 (for not actually "catching" the baby, or if the RN is the one who has actually "caught" the baby.) When you bill these, be sure to denote that the physician "missed" the delivery of the infant, but completed the balance of care. Also, be sure use the "precipitous delivery" diagnosis driver of 661.31 as our primary dx. Scenario B b) If your provider is the attending and has missed the delivery but the Nurse was in attendance: Bill the Antepartum care only (59425/26), a placenta only delivery(59414) and any vaginal repairs if needed, and post-partum care(59430) once your provider actually see the patient back in the clinic setting/office. Some carriers and 3rd party payers prefer this methodology. If you choose to bill with the above, you may also bill the placenta only delivery with diagnosis code 661.31 for preciptate labor. With ACOG's guidelines, you could then appropriately bill subsequent daily hospital visit codes(99231-99233) for the maternal hospital stay, and also a Discharge (99238-99239) If you truly only provided the "intra-partum" care, and not a full "delivery spectrum" of care. Once the patient arrives in your clinic for a 2/4/6 wk follow up, bill the 59430 post-partum care code. Scenario C c) If an outside physician or OB hospitalist (someone outside your practice or tax ID #)delivers the baby, the placenta & does any repairs, then the outside physician/hospitalist will usually bill the 59409 delivery only code. The PCP/Antepartum OB would only bill the Ante/Posts for that patient, and any other subsequent care during the delivery stay. Scenario D d) If the outside physician or OB hospitalist have a reciprocity agreement, or a Financial agreement of cross/coverage, you could then bill the global feel to the insurance carrier or 3rd party payer as OB/Gyn provider, office. You owuld then provide an outside reimbursement to the actual delivery physician or OB hospitalists service via in-house transfer/or private payment methodology. (eg. $500.00 lump sum to the OB hospitalists for the delivery only) If the hospitalists and the OB's have a reciprocity agreement in place, it would then be inappropriate to bill the OB's for a placenta only delivery and/or repairs. I am sure there are many, many more scenario's and different issues that come up in regard to "missed delivery" billing. If you are unsure, contact all proviers of care involved, and contact the insurance payers/3rd party payers to inquire as to what methodology they would like to see the claims submitted under. L : )

Wet Prep and Fern Testing in OB-GYN

Good Morning - I had a query last week regarding the criteria necessary for billing for these two tests in an OB/Gyn and OB Hospitalist office. Here's what you need to know: The FERN test: Provided the physician documents that THEY did the procurement (not a nurse or medical assistant) and personally reviewed the slide, and notated the medical record as such. The physician can then bill a HCPCS code Q0114 with dx's such as 658.13 (Premature Rupture of Membranes PROM), 646.83 (Oth antepartum complication) KOH Wet prep: Again the physician must document and be the one who procures the KOH Wetmount HCPCS Code Q0112 can be billed. This code will pass a CCI edit scrub with dx's such as 658.13 (PROM), 646.83 (Oth Antepartum complication) 623.5 Leukorrhea. It did not pass edit check for code 616.10 (Bacterial Vaginosis). Wet mounts, including preparations of vaginal, cervical or skin specimens HCPCS Code Q0111 can be billed and it passes the edits with the same dx's as above (see KOH Wet Prep) . Actual reimbursement for these would depend on the insurance carrier, or 3rd party payers, and their particular edit scrubs and/or contracts with providers. However, at this time these HCPCS codes are the valid way to code for these services provided by a physician. If these services are provided by the Laboratory, then the appropriate CPT codes from the 80000 code section would be billed. Have a GREAT day!

The Top “10’s” What can your practice learn from this?

Welcome back to my blog -  This is a copy of an article that I wrote for the OB/GYN hospitalist website.  This article is geared toward the specialty of OB/GYN hospitalists.  However, this type of data mining can be of help to any practice. As I specialize in the OB/GYN field, this excercize was really informative for me, as I wrote the article. Enjoy! 

*************************************************************************************

The Top “10’s”  What can your practice learn from this?  

In an OB Hospitalist practice, you are faced with so many different medical scenarios each and every day that to know what is your top 10 might be a difficult assignment.  Well, this is exactly what we decided to take on. 

 

We encounter patients who don’t have a regular health care provider, and those patients rely on OB hospitalists to respond to their emergencies and care for them around the clock. Because the hospitalist program is fairly new to the American hospital system, coding for this subspecialty poses a bigger challenge for the providers, as well as the hospital itself.  We have to maintain good patient care, in addition to being fiscally solvent. 

The OB-GYN hospitalist program has a positive impact on these at-risk OB patients’ health care because our programs enable these patients to have emergent care for any type of OB or GYN emergency when their own physician is unavailable.  Of course, we provide many other functions such as, supporting local obstetricians as back-up for deliveries and emergency C-sections; providing ancillary testing services for walk-in or emergent trauma situations, and also step in as an assistant surgeon for many operative procedures at a moment’s notice.  

The fiscal mainstay for the OB Hospitalist practice is the E/M services, which include all areas of inpatient hospital, outpatient hospital, emergency department, critical care and office codes.  The next area of importance is the CPT procedures, which can include surgery, interventional, diagnostic and therapeutic medicine, radiology/ultrasound services. 
In trying to ascertain the “top ten” E&M Services, this was difficult, because each OB hospitalist program functions under many different licenses within the hospital setting.  Some practices are embedded with the Emergency Room, some are an integral part of the Labor & Delivery floor, while others operate as a “emergent outpatient” area of the hospital similar to a “quick-care, urgent-care” walk in clinic.  

Each OB hospitalist practice should really take the time to figure out which “top ten” E&M services are in your practice, and evaluate how those particular E&M codes  impact your fiscal bottom line.  The next step is to look at the top ten procedures that your practice is billing for, then follow all of that up with a list of the top 10 diagnoses that are being treated within the practice.  Once you have this information it may surprise you as to what your “standard of care” really is. 

Below is a quick analysis of what I put together from an OB hospitalist practice in the Northwest.  The lists below are the analysis of the three separate areas of “top tens”
Evaluation and Management Services:

1.     99213 Office or other outpatient visit for the evaluation and management of an established patient.

2.     99201 Office or other outpatient visit for the evaluation and management of a new patient,.

3.     99214 Office or other outpatient visit for the evaluation and management of an established patient

4.     99232 Subsequent hospital care, per day, for the evaluation and management of a patient

5.     99221 Initial hospital care, per day, for the evaluation and management of a patient,

6.     99222 Initial hospital care, per day, for the evaluation and management of a patient,

7.     99234 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date,.

8.     99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components:.

9.     99217 Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status."

10. 99282 Emergency department visit for the evaluation and management of a patient,.

Our next “top ten” that we did analysis on was our procedures that we are performing. This is what we found.

Ob Hospitalist Procedures:

1. 59514-80     Assist to a surgeon for cesarean delivery
2. 59514          Cesarean delivery only;
3. 59409          Vag Deli Only
4. 59412          External cephalic version, with or without tocolysis
5. 59612          V-back
6. 59025-26     Fetal NST interpretation
7. 59160          Curettage - Post Partum
8. 59300          Episiotomy or vaginal repair, by other than attending physician
9. 58611          Tubal Ligation (Add on w/c-section)
10. 58605          Ligation or transection of fallopian tube(s),  during same hospitalization (separate procedure)

OB Hospitalist Top 10 Diagnosis for the practice:

1.       646.83  Other specified complication, antepartum

2.       644.03  Threatened premature labor, antepartum before 37 wks

3.       644.13  Threatened premature labor, antepartum after 37 weeks

4.       644.20  Early onset of delivery, unspecified as to episode of care

5.       655.73  Decreased fetal movements, antepartum condition or complication

6.       649.53  Spotting complicating pregnancy, antepartum condition or complication

7.       658.13  Premature rupture of membranes in pregnancy, antepartum

8.       646.63  Infections of genitourinary tract antepartum

9.       659.73  Abnormality in fetal heart rate or rhythm, antepartum condition or complication

10.     922.2   Contusion of abdominal wall

OB Hospitalist Top 10 +10 more  Diagnosis Cesarean Delivery

1.       644.21 Early onset of delivery, delivered, with or without mention of antepartum condition

2.       654.21 Previous cesarean delivery, delivered, with or without mention of antepartum condition

3.       659.71 Abnormality in fetal heart rate or rhythm, delivered,

4.       652.21 Breech presentation without mention of version, delivered

5.       661.11 Secondary uterine inertia, with delivery

6.       661.01 Primary uterine inertia, with delivery

7.       642.51 Severe pre-eclampsia, with delivery

8.       652.51 High fetal head at term, delivered

9.       651.01 Twin pregnancy, delivered

10.     656.31 Fetal distress affecting management of mother, delivered

11.     645.11 Post term pregnancy, delivered, with or without mention of antepartum condition

12.     648.01 Maternal diabetes mellitus with delivery

13.     658.11 Premature rupture of membranes in pregnancy, delivered

14.     656.61 Excessive fetal growth affecting management of mother, delivered

15.     658.01 Oligohydramnios, delivered

16.     658.41 Infection of amniotic cavity, delivered

17.     656.51 Poor fetal growth, affecting management of mother, delivered

18.     652.31 Transverse or oblique fetal presentation, delivered

19.     659.01 Failed mechanical induction of labor, delivered

20.     641.11 Hemorrhage from placenta previa, with delivery

As we have shared this information with you, please remember that each practice is different.  You will discover trends and opportunities that you weren’t aware of before, and your information analysis may or may not surprise you. 

Once you have this information, you can then audit and pull out areas and ideas that you may want to improve upon, such as documentation, staffing, or even how you market your practice to the community. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, 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/.