OB Coding – The Global Package & Beyond

OB Coding –g &The Global PackageBeyondKerin Draak, MS, WHNP-BC,CPC, CEMC COBGCk i d@Pkerind@Prevea.comYou Will Learn How to code for routine pregnancy servicesg What services are billable outside the OB globalpackage How documentation is required to lookto support routine care1

Before Pregnancy .aka Preconception Care Preconception care consists of identifying thoseconditions that could affect a future pregnancy, andthat may be amenable to intervention. Dx code V26.49: Other procreative management,counseling and advice CPT code 99401-9940499401 99404Pregnancy – But Before OB Global How to bill for encounter to diagnose pregnancy– Patient presents with symptoms– Patient calls with ( ) home pregnancy test2

Example Office Note 25yo, sexually active, SWF, here with CC of nausea x3 weeks intermittently.intermittently Reports irreg menses and usescondoms for birth control. Denies fevers or emesis. Exam: ( ) UPT, Pt pale, no acute distress, Pelvicexam: No CMT, Uterus about 6-8 weeks size Early pregnancy, unknown dates. Scheduletransvaginal U/S. Rx for PNV faxed in.Example Office Note 25 yo, sexually active, SWF called earlier today with( ) homehUPT lastl t night.i ht UPT ini theth officeffi todayt d wasalso ( ). Pt reports irreg menses with ? LMP.Discussed with MD and he suggests that the pt bescheduled for an U/S later this week and start on aPNV. Pt in agreement with POC. Note signed by medical assistant.assistant3

Example Office Notes 25 yo, sexually active, SWF called earlier today statingthat she had ( ) home UPT last night. Per MD’s POCon date XYZ, the pt presents for a UPT and pregnancycounseling today under the direct supervision of MD.Test here was also ( ). Discussed with pt diet changes,exercise limits, s/s to call office, reviewed early s/s ofnormal pregnancy. Pt reports irreg menses with ? LMP.DiDiscussedd withith MD andd heh suggestst thatth t theth ptt bebscheduled for an U/S later this week and start on aPNV. Pt in agreement with POC.Pregnancy Test Codes Dx Codes– V72.40:V72 40: Pregnancy examination or testtest, pregnancyunconfirmed (aka possible pregnancy, notconfirmed yet)– V72.41: Pregnancy examination or test, negativeresult– V72.42:V72 42: Pregnancy examination or test,test positiveresult4

During Pregnancy .aka Antepartum Care Accordingg to CPT ,, maternityy care anddelivery are those services normally providedin uncomplicated maternity cases. CPT also states that any other visits orservices within this time period should becodedd d separately.t lAntepartum Care CPT guidelines list the following services in theantepartum care package:– Initial and Subsequent history and physicalexams– Weight, blood pressure, fetal heart tones,routine chemical urinalysis– Monthly visits up to 28 weeks (5(5-66 visits)– Biweekly visits up to 36 weeks (4 visits)– Weekly visits until delivery (3-4 visits)5

First OB Visit Who performs the first OB?y historyy and counselingg Visit dominated by– Consider billing based on time. Total time of face-to-face encounter Total time spent in counseling and/orcoordinating care BriefB i f descriptiondi ti regardingdi theth itemsitdiscusseddidor activities of coordinating careExcluded Antepartum Services Conditions unrelated to the pregnancy ConditionsC di irelatedl d to theh pregnancy Procedures6

Excluded Antepartum Services Conditions not related to the pregnancy.– UTI– URI– VaginitisExample NoteDatewksFH cmFMFHRS/SPTLUrineBPWt2/102424 neg128/78 145NotesT 100.7 URIOTC meds, RTC 1week7

Example Note Pt is 24 weeks here for routine OB check. Pt denies any vaginalbleeding or contractions. Reports ( ) FM. Feeling tired at the end ofy She also has some cold symptomsy pof nasal congestiongandthe day.cough for the last 4 days and wants to know what she can take. Deniesfever or sore throat. On exam, Fundal ht of 25 cm. BP 128/78, Wt 145, T.100.7, Negketones, No edema, HEENT: eyes clear and watery, Ears with fluid,but not red nor bulging, Nose swollen turbinates and clear discharge,Neck and nodes slight swollen and tender, LS clear, HR RRR 24 weeks gestation, S D, No S/S of PTL, Viral URI Next OB check at 28 weeks, conservative treatment measuresdiscussed. If symptoms persist or worsening after 4-5 days, to call backand will consider antibiotics. Pt is agreement with POC.Excluded Antepartum Services Conditions related to the pregnancy– Preterm Labor (PTL)– Decreased Fetal Movement (FM)– Pre-eclampsia– Diabetes– GestationalG t ti l diabetesdi b t– Hyperemesis8

Excluded Antepartum Care PTL in first pregnancy additional monitoringin current pregnancy delivers at term Noadditional visits billed PTL in first pregnancy additional monitoringin current pregnancy Pt develops PTL asevidenced byy ppremature dilation andcontractions, Pt put on bedrest Additionalvisits billedOB Flowsheet & Documentation History– Date– Weeks gestation– Fetal movement– S/S PTL– Pain Exam– BP,BP Wt– Ketones– Edema– Cervix exam– Fetal heart rate– Uterine size/Fundal ht– Fetal presentation9

Excluded Antepartum Services Procedures– Non-stressNtest (NST)– Ultrasounds– Amniocentesis– Chrorionic villus sampling (CVS)– Fetal biophysical profile– External cephalic versionExample Office Note Pt presents at 33 weeks with CC of decreased FM forthe past week and hasn’t felt the baby move thismorning. Denies abdominal pain or contractions, deniesbleeding. BP 128/76, Wt 156, Fundal ht 34 cm, Abdomen soft,Able to palpate FM, but pt couldn’t feel. Placed onNST. Reactive NST, S D, Pt to RTC next week for routineOB check. Instructed on kick counts. Much reassurancegiven.10

OB FlowsheetDatewksFH cmFMFHRS/SPTLCervixexamBPWt2/103334 cm NST n/a128/76 156Urine Notes ( ) NST, RTC 1weekNST Note According to CPT , “Results are the technicalcomponent of a service. Testing leads to results;resultsl leadl d to interpretation.ii Reports are thehwork product of the interpretation of testresults.” Some procedures have a technical component(eg, tests) that produces results (eg, tracing,image), and these results require a professionalcomponent (interpretation of the results)11

NST TracingNST Procedure Code 59025 Components of a NST– VariabilityV i bili Short term variability (STV) Long term variability (LTV)– Accelerations, decelerations– Baseline variability (BL)– Uterine activity12

Ultrasounds Standardize reports and interpretations Practice guidelines through the AIUM(American Institute of Ultrasound inMedicine) Practice guidelines through ACOG (AmericanCollege of Obstetricians and Gynecologists)Ultrasounds Transabdominal–––––76801: 14 weeks76801k 76802: each add’l gestation76805: 14 weeks 76810: each add’l gestation76811: fetal and maternal evaluation pluspdetailed fetal anatomic exam– 76812: each add’l gestation13

Ultrasounds Transabdominal– 76815: limited exam 1 or more fetuses– 76816: ‘follow-up’ Transvaginal– 76817: only OB transvaginal ultrasound,doesn’t specify gestational age Transabdominal OR Transvaginal– 76813: fetal nuchal translucency– 76814: each add’l gestation14

Hospital Setting Inpatient– InitialI i i l HospitalH i l CareC (99221-99223)(99221 99223)– Inpatient and/or Observation SameDay (99234-99236) Outpatient– ObservationObti (99218-99220)(99218 99220)– Inpatient and/or Observation Same DayHospital Inpatient Initial Hospital Codes (99221-99223)– Require faceface-to-faceto face encounter in the hospital– Admitting from office– Patient presents to hospital and you admit viaverbal order Need to use “AI” modifier (Medicare modifier) Do not report within 24 hours of delivery forestablished patients15

Initial Hospital Care CodesCodeHistory HPI ROS PFSHExam1995 DGMDMTime992219922299223Detailed4 2-92 areasDetailed22-77SF to LowComp4 10 All 3Comp88 organsModerateComp4 10 All 3Comp88 organsHigh30 Min50 Min70 MinObservation CareCodeHistory HPI ROS PFSHExam1995 DGMDM99218Detailed4 2-92 areasDetailed2-7SF to Low99219Comp4 10 All 3Comp8 organsModerate99220Comp4 10 All 3Comp8 organsHigh16

Observation Care – Same DayCodeHistory HPI ROS PFSHExam1995 DGMDM99234Detailed4 2-92 areasDetailed2-7SF to LowSame Calendar DayInpatient Care 8 hours99221-99223 Discharge code 8 hours99234-99236Provider mustsee twiceObservation Care 8 hours99218-99220 Discharge code 8 hours99234-99236Provider mustsee twice99235Comp4 10 All 3Comp8 organsModerate99236Comp4 10 All 3Comp8 organsHighTwo Calendar DaysInpatient CareOutpatient CareDay 1: 9922199223Day 2: 9923899239Day 1: 99218-99220Day 2: 99217If the documentation doesn’t meet thelowest level of service, report 99499.17

After Pregnancy aka Postpartum Care History– Feeding method– Bleeding– Birth control– GI/GU– Postpartumdepression screen Exam– VS– Thyroid– Breasts– Abdomen– GU/PelvicPostpartum Example Note 29yo, G1P1 who delivered at 39 weeks presentsfor her 6 week postpartumpostpartum. She had a NVD withnd2 degree epis. PP Hct was 11.9. She is breastfeeding baby and denies breast/nipple problems.No GI/GU concerns. Her bleeding stopped justlast week. She says that her bottom is feelingbetter,, but thinks there still mightg be a stitchthere. She has not had intercourse since deliveryand plans to go on the mini pill.18

Postpartum Example Note (cont) On exam, VSS, Thyroid not enlarged, Breastsnormal to inspectioninspection, nipple pinkpink, no palpationas she is getting close to a feeding. Abdomendoughy with hernia. Slight separation ofdiastasis recti. External genitalia atrophic, epishealed. There is a small stitch that was easilyppulled out. Specp exam,, vaginag also slightlyg yatrophic, Cervix pink. Bimanual, Uterus NSSCwithout adex fullness. RV confirms.Postpartum Example note (cont) Assessment: 6 week postpartum doing wellwith no contraindications to starting onMicronor. Rx called in for 4 months. RTCfor her yearly physical and pap. Willrecheck HCT at that time. TCB as needed.19

Postpartum Example note with CC 29yo, G1P1 who delivered at 39 weeks presentspand complainspthat herfor her 6 week ppostpartumndbottom is sore. She had a NVD with 2 degreeepis. PP Hct was 11.9. She is breast feeding babyand denies breast/nipple problems. Her bleedingstopped just last week. She says that her bottomfeels ‘tight’ and it itches. She is voiding OK, but itstingsiwhenh theh urinei touchesh theh perineum.iSheShhas not had intercourse since delivery and plans togo on the mini pill.Postpartum Example note (cont) On exam, VSS, Thyroid not enlarged, Breastsnormal to inspection, nipple pink, no palpation asshe is getting close to a feeding. Abdomendoughy with hernia. Slight separation of diastasisrecti. External genitalia atrophic, and beefy red,epis healed. Spec exam, vagina also slightlyatrophic Cervix pink.atrophic,pink Wet prep obtained.obtainedBimanual, Uterus NSSC without adex fullness.RV confirms.20

Postpartum Note (cont.) Assessment. 6 week postpartum doing wellwith no contraindications to starting onMicronor. Rx called in for 4 months. Wetprep was personally interpreted and ( ) foryeast. Yeast vaginitis. Rx given for Terazol7. RTC for her yearly physical and pap.Will recheck HCT at that time. TCB asneeded.Excluded Postpartum Services Delayed postpartum hemorrhage InfectionI f i (i.e.(i UTI,UTI URI,URI endometritis)dii ) Mastitis– Modifier 24 on the separate E/M during globalwhether inpatient or outpatient21

OB Global Codes 59400:59510:59610:59618:Vaginal deliveryPrimarPrimary C/SVBACFailed VBAC, Repeat C/SGlobal Delivery Services Admission H&PInduction of laborInsertion of cervical dilator on same day as deliverySimple removal of cerclageManagement of uncomplicated laborDelivery (vaginal or cesarean)– Episiotomy, forceps or vacuum– ***IF 3rd or 4th degree repair then add modifier 22*** Delivery of placenta Routine follow-up inpatient care22