Hint: You can report complications before or after delivery.
You can receive increased reimbursement when your ob-gyn provides additional visits outside of the normal global ob package, but you’ll have to make sure you’ve coded high-risk or complicated obstetrical care correctly – and that means perfecting your ICD-9 coding skills.
Insist on Perfect ICD-9s
You have to link the ICD-9 code on the CMS-1500 claim form (boxes 21 and 24E) to an E/M code, for example, to demonstrate the reason for the additional service. You can add this to the claim that includes the global service, or you can submit it as an additional claim.
Example: A 33-year-old patient, gravida 3, para 2 (both normal spontaneous vaginal delivery [NSVD] full term), is seen in the office 19 times due to developing pre-eclampsia. After the delivery, you review the case and find that the patient required six additional visits (beyond the usual 13) for this care. The documentation for three of these visits supports reporting 99212 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 10 minutes face-to-face with the patient and/or family), while three of the visits have more extensive documentation that supports reporting 99213 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 15 minutes face-to-face with the patient and/or family).
In addition, after delivery, the patient experiences prolonged pain and irritation due to a hemorrhoid. The ob-gyn sees her for a thrombosed hemorrhoid, which he incises in the office two weeks post-delivery. Finally, the ob-gyn rechecks the patient at her six weeks postpartum visit.
Break it down: When coding for this patient, remember the claim form must note both the CPT codes describing the additional services, as well as the diagnoses that depict why the patient required the additional services.
Heads up: Notice the fifth digits of these ICD-9 codes. The digit “3″ that occurs in most of these codes has become a “4″ in the last ICD-9 code to indicate a postpartum condition rather than an antepartum one. In other words, the patient has been discharged from the hospital after giving birth. Using “3″ indicates she did not deliver during the hospital stay.
ICD-10: When your diagnosis code system changes in 2013, you should look to the following equivalents: 642.41 & 642.43= 014.00 Mild pre-eclampsia, unspecified trimester
- O14.02 — Mild pre-eclampsia, secondtrimester
- O14.03 — Mild pre-eclampsia, third trimester
- O14.90 — Unspecified pre-eclampsia, unspecified trimester
- O14.92 — Unspecified pre-eclampsia, second trimester
- O14.93 — Unspecified pre-eclampsia, third trimester
- V27.0= Z37.0, Single live birth
- 671.84=O87.2, Hemorrhoids in the puerperium
When to Submit Your Claim
You have two options as to when to submit your claim – after the patient delivers, when you can count the number of visits beyond the global ob package, or during her pregnancy when the complication occurs.
Option 1: Most coders recommend the former option. The extent to which complications create more work for the ob-gyn isn’t calculable until after the delivery, so you may wait until that point to decide what extra services to code. Best bet: To ensure you’re not losing revenue in this regard, you should have a system for carefully reviewing patient records to make sure you coded any charges beyond the global.
Option 2: If you want to report additional visits and services during the pregnancy, you should make sure your ICD-9 codes describing the patient’s condition link to the appropriate code (such as the hemorrhoids diagnosis matching the CPT code to remove them). If you’re paid additional reimbursement for these services, but the patient delivers early so that the total number of antepartum visits did not exceed the global package, you may have to return some of the overpayment.
Red flag: Some payers have specific guidelines for visits or other services paid outside the global package, so you should check with them so see which option you should use. Keep in mind: The term “high-risk” may represent a current complication, or it may involve a concern that the pregnancy may not go well due to previous history. Payers generally recognize complications, but they do not allow extra for the obgyn merely worrying about the pregnancy.
For more denial busting ob-gyn tips, subscribe to Ob-Gyn Coding Alert, by Suzanne Leder, CPC, COBGC.
