Obstetric and Gynecology Care Coding / Billing Guidelines

Obstetric and Gynecology Care Coding / Billing Guidelines

Obstetrics and Gynecology Care / Maternity care services are, 

1. Antepartum care
2. Delivery services
3. Postpartum care

There are 2 type of OB coding/billing guidelines are given below,

1. Global OB Care
2. Non-global OB care or partial services

Global OB Care

The total obstetric care package includes the provision of antepartum care, delivery services and postpartum care.

When the same group physician and/or other health care professional provides all components of the OB package, report the Global OB package code.

The CPT for Global OB codes are,

59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

59510 – Routine obstetric care including antepartum care, cesarean delivery, and postpartum care

59610 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

59618 – Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery

Billing Guidelines

The global maternity allowance is a complete, one-time billing which includes all professional services for routine antepartum care, delivery services, and postpartum care.

The fee is reimbursed for all of the member’s obstetric care to one provider.

If the member is seen four or more times prior to delivery for prenatal care and the provider performs the delivery, and performs the postpartum care then the provider must bill the Global OB code.

Global maternity billing ends with release of care within 42 days after delivery. Global OB care should be billed after the delivery date/on delivery date.

Services Included In Global Obstetrical Package,

• Routine prenatal visits until delivery, after the first three antepartum visits
  
• Recording of weight, blood pressures and fetal heart tones
  
• Admission to the hospital including history and physical
  
• Inpatient Evaluation and Management (E/M) service provided within 24 hours of delivery
  
• Management of uncomplicated labor
  
• Vaginal or cesarean section delivery
  
• Delivery of placenta (CPT code 59414)
  
• Administration/induction of intravenous oxytocin (CPT code 96365-96367)
  
• Insertion of cervical dilator on same date as delivery (CPT code 59200)
  
• Repair of first or second degree lacerations
  
• Simple removal of cerclage (not under anesthesia)
  
• Uncomplicated inpatient visits following delivery
  
• Routine outpatient E/M services provided within 42 days following delivery
  
• Postpartum care after vaginal or cesarean section delivery (CPT code 59430)
  

The above mentioned services are not separately reimbursed when reported separately from the global OB code.

As per ACOG (American College of Obstetricians and Gynecologists) coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614)

Claims submitted with modifier 22 must include medical record documentation that supports the use of modifier.

Services Excluded from the Global Obstetrical Package,

The following services are excluded from the global OB package (CPT codes 59400, 59510, 59610, 59618) and may be reported separately.

• First three antepartum E&M visits
  
• Laboratory tests
  
• Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828)
  
• Amniocentesis, any method (CPT codes 59000 or 59001)
  
• Amniofusion (CPT code 59070)
  
• Chorionic villus sampling (CPT code 59015)
  
• Fetal contraction stress test (CPT code 59020)
  
• Fetal non-stress test (CPT code 59025)
  
• External cephalic version (CPT code 59412)
  
• Insertion of cervical dilator (CPT code 59200) more than 24 hr before delivery
  
• E&M services which is unrelated to the pregnancy (e.g. UTI, Asthma) during antepartum or postpartum care.
  
• Additional E/M visits for complications or high risk monitoring resulting in greater than the typical 13 antepartum visits. However these E/M services should not be reported until after the patient delivers. Append modifier 25 to identify these visits as separately identifiable from routine antepartum visits.
  
• Inpatient E/M services provided more than 24 hrs before delivery
  
• Management of surgical problems arising during pregnancy (e.g. Cholecystectomy, appendicitis, ruptured uterus)

Non-global OB care, or partial services

Non-global OB care, or partial services, refers to maternity care not managed by a single provider or group practice.

Billing for non-global OB or Partial care may occur if,

• A patient transfers into or out of a physician or group practice
  

• A patient is referred to another physician during her pregnancy
  

• A patient has the delivery performed by another physician or other health care professional not associated with her physician or group practice
  

• A patient terminates or miscarries her pregnancy
  

• A patient changes insurers during her pregnancy

The physician provide only partial services instead of global OB care, T bill for that portion of maternity care only.

Use the codes below for billing antepartum-only, postpartum-only, delivery-only, or delivery and postpartum only services.

Only one of the following options should be used, not a combination.

A. Antepartum care only

• For 1 to 3 visits: Use E/M office visit codes.
  
• For 4 to 6 visits: Use CPT 59425, This code must not be billed by the same provider in conjunction with one to three office visits, or in conjunction with code 59426.
  
• For 7 or more visits: Use CPT 59426 – Complete antepartum care is limited to one beneficiary pregnancy per provider.

Billing Guidelines

If the patient is treated for antepartum services only, the physician should use CPT code 59426 if 7 or more visits are provided, CPT code 59427 if 4-6 visits are provided, or each E/M visit if only providing 1-3 visits.

As per ACOG and AMA guidelines, The antepartum care only codes 59425 or 59426 should be reported as described below,

• A single claim submission of CPT code 59425 or 59426 for the antepartum care only, excluding the confirmatory visit that may be reported and separately reimbursed when the antepartum record has not been initiated.
  
• The units reported should be one.
  
• The dates reported should be the range of time covered,
  

E.g. If the patient had a total of 4-6 antepartum visits then the physician should report CPT code 59425 with the from and to dates for which the services occurred.

• CPT 59425 and 59426 – These codes must not be billed together by the same provider for the same beneficiary, during the same pregnancy.
  
• Pregnancy related E/M office visits must not be billed in conjunction with code 59425 or 59426 by the same provider for the same beneficiary, during the same pregnancy.

B. Delivery services only

The following are the delivery CPT codes,

CPT 59409 – Vaginal delivery only (with or without episiotomy and/or forceps)

CPT 59514 – Cesarean delivery only

CPT 59612 – Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)

CPT 59620 – Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery

The delivery only codes should be reported by the same group physician for a single gestation when,

• The total OB package is not provided to the patient by the same physician or group practice.
  
• Only the delivery component of the maternity care is provided and the postpartum care is performed by another physician or group of physicians.
  

Services included in the delivery services

      As CPT and ACOG guidelines the following services are included in the delivery services codes and shouldn’t be reported separately.

• Admission to the hospital,
  
• The admission history and physical examination,
  
• Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery, external and internal fetal monitoring provided by the attending physician
  
• Intravenous induction of labor via oxytocin (CPT code 96365-96367)
  
• Delivery of the placenta, any method
  
• Repair of first or second degree lacerations
  

Insertion of cervical dilator (CPT 59200) to be included if performed on the same date of delivery.

Reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614)

Claims submitted with modifier 22 must include medical record documentation which supports the use of modifier.

C. Delivery only including postpartum care

If the same individual or Same group physician provided the delivery care and postpartum care, in these instances few CPT code has encompass both of these services, The following are CPT defined delivery and postpartum care.

CPT 59410 – Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

CPT 59515 – Cesarean delivery only; including postpartum care 

CPT 59614 – Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care

CPT 59622 – Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care

Services included in the delivery only including postpartum care services

• Hospital visits related to the delivery during the delivery confinement
  
• Uncomplicated outpatient visits related to the pregnancy
  
• Discussion of contraception
  

D. Postpartum Care Only

The following is the CPT defined postpartum care only,

CPT 59430 – Postpartum care only (separate procedure)

Services included in the postpartum care

• Uncomplicated outpatient visits related to the pregnancy
  
• Discussion of contraception
  

Services Excluded in the postpartum care

• E/M of problems or complications related to the pregnancy
  

Billing Guidelines

The postpartum care only should be reported by the same group physician provides the patient with services of postpartum care only.

If a physician provides any component of antepartum along with postpartum care, but does not perform the delivery, then the services should be itemized by using the appropriate counterpart care code and postpartum care code.


REFERENCES:

http://www.uhccommunityplan.com/content/dam/communityplan/healthcareprofessionals/reimbursementpolicies/R0064-ObstetricalServicesPolicy.pdf

http://www.acog.org/Resources-And-Publications

https://www.pacificsource.com/searchresults.aspx?searchtext=59400

https://www.oxhp.com/secure/policy/obstetrical_policy.pdf