By Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC
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:
Q: Is billing an evaluation and management (E/M) code along with CPT® code 0501F (prenatal flow sheet documented in medical record by first prenatal visit [documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery]. Report also: date of visit and, in a separate field, the date of the last menstrual period) allowed on an initial OB appointment when the confirmation of pregnancy is done at the same appointment? If not, what way, other than servicing the patient at two separate appointments, can we be reimbursed for both the initial (global) and the confirmatory appointment?
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, is that first visit billable or is it part of the global package?
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 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.
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 the baby is also Rh-negative?
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:
- The first dose of Rho(D) immune globulin is to be given at 28 weeks’ gestation (earlier if there’s been an invasive event)
- This should be followed by a postpartum dose given within 72 hours of delivery
Q: With the prenatal visits and the delivery as separate from the OB package you would always append modifier -59 (distinct procedural service) to the delivery? My understanding is that modifier -59 is used only for procedure-to-procedure needs.
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:
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.”
Q: Are we able to bill an E/M visit if a pap smear was performed at the postpartum appointment?
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):
- Postpartum visit ( on or between 21 days and 56 days after delivery)
- Pelvic exam and/or weight, BP, breast, and abdomen exam.
- Screen for postpartum depression. Refer for intervention if indicated.
- Screen for domestic violence.
- Discuss sexual activity and contraception with an emphasis on the benefits of long-acting reversible and/or non-reversible contraception.
- Review nutrition and exercise.
- Discuss method of feeding (breast or bottle).
Q: If a pap smear is performed in the middle of the pregnancy, is it billable?
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.
Q: When would we use ICD-10-CM code Z33.1 (pregnant state, incidental)?
A: In the guidelines from ICD-10-CM, instructions for Chapter 15 relating to 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.
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:
- S93.401A, sprain of unspecified ligament of right ankle, initial encounter
- Z33.1
- Z3A.23, 23 weeks gestation of pregnancy
Q: We have had cases where our MD has been called to the labor area (and sometimes even the ED) as the patient came in thinking she was in labor. However, labor was ruled out. Sometimes the patient just had 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 patients thought they were leaking but really weren’t, especially using the codes available in ICD-10-CM.
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.
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 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 email at [email protected] or find current coding information on her blog: http://lori-lynnescodingcoachblog.blogspot.com. For more information, see the HCPro webcast Unbundle the Pregnancy Package and Manage ICD-10 Changes.
HCPro.com – JustCoding News: Outpatient
