In a previous column, I answered questions from coders who watched my previous webcast about the coding for the pregnancy package and new concepts added in ICD-10-CM. I got so many great questions that I wanted to make sure I answered all of them. I’m sure many coders are facing similar scenarios.

 

I’ll start by answering two similar questions that came up after the show:

 

 

A: As per the American Congress of Obstetricians and Gynecologists (ACOG) guidelines, which most OB practices try to follow, ACOG presented the following information as their recommendation when reporting the confirmation of the first pregnancy visit:

 

 

The above information was taken directly from the ACOG website. However, in my opinion regarding the billing the E/M along with Category II code 0501F for the initial OB appointment, I consider the “OB start antenatal” at the time the OB flowsheet 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 is scheduled at a later date to begin the OB intake and flowsheet 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 to begin the evaluation/OB flowsheet at the same encounter.

 

 

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 whether to have 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.

 

ACOG has developed a standard guideline of re-administration of the Rho(D) immune globulin product

These standards are: 

 

 

A: Modifier -59 should not be appended to the codes when an “unbundled” delivery is billed 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 the provider 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 the claim information note line, you should denote “antepartum care only.” Codes 59425 (antepartum care only; 4-6 visits) or 59426 (antepartum care only; 7 or more visits), or E/M codes, denote 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.

 

The 2015 CPT Manual defines modifier -59 as follows:

 

 

 

A: In a normal postpartum service visit, as part of the global package, a pap smear is commonly performed as routine testing 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., code 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 or postpartum related) then an E/M code would be billable and the procurement of the scraping is bundled into the E/M service. Modifier -24 (unrelated E/M service by the same provider during a postoperative period) would also need to be appended on the physician claim.

 

According to the postpartum care guidelines put forth by CPT and ACOG, the following is what is normally provided during the postpartum period at the time of the postpartum pelvic exam (which would be when the pap smear scraping/procurement would take place):

 

 

 

A: If a pap smear is performed during the middle of the pregnancy, it would be billable. The need for a pap smear would have to be medically necessary and a separately identifiable diagnosis. The pap smear is normally considered a routine part of prenatal care. If a patient does have an abnormal pap smear 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 smear itself is bundled into the E/M and the pap test itself (e.g., code 88175) would also be billed with the diagnosis appended.

 

 

 

A: In the guidelines from ICD-10-CM, instructions for Chapter 15 relating to sequencing priority state:

 

 

What this means is if the patient presents with a separately identifiable diagnosis that is not related to the pregnancy, but the patient is pregnant, 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 an unspecified ligament of the right ankle, initial encounter.

 

This would be coded as:

 

 

 

A: That is always a tough call, but the patient did arrive to an "emergency" type area. I have used ICD-10-CM code O99.89 (other specified diseases and conditions complicating pregnancy, childbirth, and the puerperium) and I have also used O47.- (false labor) if the provider clearly documents 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 (e.g., vaginal leaking, pelvic pressure, etc.). This additional information added to the claim helps clarify to the third-party payer/carrier exactly what the other disease, symptom, or condition is. Don’t forget to add the Z3A.- weeks of gestation code to provide information to the carrier how far along in the pregnancy the patient is.