Obstetric and Gynecologic CPT Coding AAPC Chapter Meeting Presented by: Deb Kuehn, CPC, CMRS July 18, 2013 Overview • Global OB Coding and guidelines for use • Review individual and package coding for OB services not part of a Global • Medicare GYN coverage – criteria and coding guidelines • Other GYN services and procedures • Diagnosis coding for OB and GYN services • Medical Necessity 2 Global codes for OB Care • CPT codes for global OB care are: o o o o 59400 Total OB care with routine vaginal delivery 59510 Total OB care with routine cesarean delivery 59610 Total OB care with routine VBAC delivery 59618 Total OB care with routine repeat cesarean delivery after attempted VBAC delivery 3 Component Codes for OB care o CPT codes for providers who do not furnish the entire global package are: o 59409 Vaginal delivery only (with or without episiotomy and/or forceps); o 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care o 59425 Antepartum care only; 4-6 visits o Less than 4 antepartum visits should be coded with the appropriate E/M level o 59426 Antepartum care only; 7 or more visits o 59430 Postpartum care only (separate procedure) 4 Component codes for OB care • 59414 Cesarean delivery only • 59415 Cesarean delivery only; including postpartum care • 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) 5 59400 and 59510 Global Routine Obstetric Care • These CPT codes are inclusive of: – Antepartum care, – 59400 - Vaginal delivery (with or without episiotomy, and/or forceps) 59510 Cesarean delivery (with or without episiotomy, and/or forceps) and – Postpartum care • The rules that pertain to the use of this code include a) The provider billing for OB care must have rendered at least 3 months of consecutive antepartum care to the recipient. b) The date the provider first saw the recipient for antepartum care must appear in block 15 of the CMS-1500 form. c) The date of service on the claim for the OB care must be the date of delivery. d) These codes cannot be billed in addition to other OB global codes. 6 Antepartum Care • Several of the global delivery CPT codes include the term “Routine Antepartum Care”. This is defined as: – Monthly visits up to 28 weeks gestation – Biweekly visits to 36 weeks gestation, and – Weekly visits until delivery For high risk pregnancies requiring more than the “routine” care additional E/M visits may be coded separately using CPT codes 99212-99215 as appropriate. NOTE: Recommend practices mark high risk patient charts for audit for additional visits when billing for the global care. 7 Routine Vaginal Delivery INCLUDES: Care provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum care: Admission history Admission to hospital Artificial rupture of membranes Management of uncomplicated labor Physical exam Vaginal delivery with or without episiotomy or forceps EXCLUDED: Are medical or surgical complications fo the pregnancy including hernia repair, excision or destruction of bartholin or ovarian cysts and treatment of other medical problems such as cardiac or endocrine disorders. 8 Postpartum Care • The postpartum period includes 60 days of follow-up care after the date of delivery. • Postpartum care is not reimbursed separately when an OB global code is billed. • Medicaid reimburses providers for family planning procedures, including sterilization, when provided during this period. • The spans of dates during and after the pregnancy are very different than the spans of dates typically associated with minor and major surgical pre- and post-operative periods. • When a provider renders services on the date of delivery or during the postpartum period that are unrelated to the actual pregnancy or delivery, the provider can bill an Evaluation and Management (E/M) procedure code appended with modifier 24 or 25, as applicable. • NOTE – Be sure to use the diagnosis code that supports the medical necessity of the additional service to assist in payment. 9 59409 and 59410 – Delivery and Delivery/Postpartum care only • 59409 – this CPT denotes that the physician delivering the infant is only providing the delivery portion of the care. • Most often occurs if another physician outside of the group has to deliver. • Does not include any antepartum or postpartum care. • If the delivering physician (who did not provide any care prior to the birth) also providers postpartum care use code 59410 for both the delivery and postpartum care. • If the delivering physician did see the patient for antepartum care, but it was 3 visits or less, then those should also be coded with the appropriate E/M code. 10 59414 – Delivery of Placenta (Separate Procedure) • CPT Code 59414 – Delivery of Placenta should only be reported when the procedure is done separately from the routine delivery. • If performed immediately following the delivery it is included in the global charge. • Example of where it would be separately billable include: – Placenta is retained and requires another provider to deliver at an interval following the delivery 11 59425 Antepartum Care only (4-6 visits) and 59426 (7 or more visits) • The provider billing for OB care must have rendered at least 3 months of consecutive antepartum care to the recipient. • The date the provider first saw the recipient for antepartum care must appear in block 15 of the CMS1500 form. • The date of service on the claim must be the date of delivery. • This code cannot be billed in addition to other OB global codes. • A provider can bill this code once during the pregnancy with one unit. • Delivery and postpartum care are to be billed in addition to this code 12 • 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery • 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery • 59621 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care • NOTE – When coding for cesarean delivery make sure you know how previous pregnancies were delivered. These codes carry a higher reimbursement that routine cesarean delivery itself. 13 Obstetric Diagnosis Coding • Coders must make sure they understand which diagnosis and procedure codes are appropriate for obstetric/maternity services. • ICD-9-CM codes 630–679 are specific to the mother and what is happening to her. • Codes 760–779 are for the fetus/neonate/baby. NOTE - It is important to know whether you are coding for the mother, the baby, or both, and assign the appropriate set of diagnosis codes. 14 Diagnosis coding for Obstetrics • ICD-9 codes for routine global OB care are: o 650 Routine vaginal delivery, and the appropriate V27.x code for the outcome of the delivery. o 654.21 Prior cesarean section delivery used for repeat c-section and for VBAC delivery, and the appropriate V27.x code for the outcome of the delivery. o Primary cesarean section delivery ICD-9 codes should be the diagnosis code for the condition requiring c-section delivery (eg, obstructed labor 660.xx, or abnormality forces of labor 661.xx), and the appropriate V27.x code for the outcome of the delivery. 15 Routine OB Diagnosis Codes • ICD-9 codes for routine global OB care include: • 650 Routine vaginal delivery, and the appropriate V27.x code for the outcome of the delivery. • 654.21 Prior cesarean section delivery used for repeat csection and for VBAC delivery, and the appropriate V27.x code for the outcome of the delivery. • Primary cesarean section delivery ICD-9 codes should be the diagnosis code for the condition requiring c-section delivery (e.g., obstructed labor 660.xx, or abnormality forces of labor 661.xx)., and the appropriate V27.x code for the outcome of the delivery. 16 Fetal Biophysical Profile with NST 76818 - Fetal • Are covered for additional fetuses. biophysical profile; • The first fetus should be billed on one with nonstress detail line, no modifier with 1 unit of testing service. 78819 - Fetal biophysical profile; without nonstress testing Additional fetus(es) should be billed on the next detail line with modifier 59,and the number of units should equal the number of additional fetuses 17 Ultrasounds • Ultrasounds are covered when medically necessary. • Medicaid covers three ultrasounds within 280 days for the same or different provider for normal pregnancy. • If additional ultrasounds are required, the diagnosis code must indicate high-risk conditions warranting additional ultrasounds. • NOTE – If taking a transfer OB patient be sure to obtain copies of the patient’s records to confirm treatment which may have time or unit limitations. 18 Ultrasounds for Multiple Fetuses • Claims denied for additional ultrasounds may be resubmitted as an adjustment with documentation to support the medical necessity of a repeat ultrasound on the same date of service. • In cases of fetal demise, the ultrasound procedure that confirms the loss of one or more fetuses may be billed with units to include the total number of additional fetuses, dead and living. • Subsequent billings should be billed with the units based on the number of “each additional” living fetus 19 Medicare Coverage for GYN • Comprehensive preventive exams i.e. Well Woman are never covered • However, Medicare does cover certain components of GYN care for it’s female beneficiaries. These include: Pelvic/clinical breast exam (G0101) Screening Pap test (Q0091) Screening hemoccult (82270 or 82272) Screening mammography (77057) Bone mass measurement (77080-77082) 20 Medicare Coverage for GYN (cont.) Initial Preventive Physical Examination (IPPE within 6 months of Medicare enrollment)** Diabetes screening and self management (G0108) Cardiovascular screening Depression and alcohol abuse screening Smoking Cessation counseling (G0436 up to 10 minutes, G0437 greater than 10 minutes) Annual wellness examination with personalized prevention plan of service (G0438 initial visit and G0439 subsequent visit) 21 Initial Annual Wellness Visit (AWV) • The initial annual wellness visit (AWV) includes : taking the patient's history; compiling a list of the patient's current providers; taking the patient's vital signs, including height and weight; reviewing the patient's risk factor for depression; identifying any cognitive impairment; reviewing the patient's functional ability and level of safety (based on observation or screening questions); setting up a written patient screening schedule; compiling a list of risk factors, and furnishing personalized health services and referrals, as necessary. 22 Subsequent Annual Wellness Visit (AWV) The subsequent annual wellness visits (AWV) includes: updating the patient's medical and family history, updating the current provider list, obtaining the patient's vital signs and weight, identifying cognitive impairment, updating the screening schedule, updating the risk factors list, and providing personalized health advice to the patient. 23 Guidelines for Collection of Pap Smears • Pap smear CPT codes should not be used to bill collection of a specimen. • Collection of the smear is included in the reimbursement for office visits and no separate fee is allowed. • Providers who do not perform the lab test should not bill the pap smears. • Only the provider who actually performs the lab test should bill the pap smear codes, except as noted below for physician interpretation. • NOTE – CPT code 99000 is not appropriate to bill for sending the pap sepecimen to the lab. This code should only be billed for specimens sent to a lab where the physician incurs an additional cost for transportation. 24 Medicare IPPE** • G0402 Initial preventive physical examination; face-toface visit, services limited to new beneficiary during the first 12 months of Medicare enrollment • G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report • G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination • G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination 25 Screening Pelvic and Clinical Breast Exam (CPT Code G0101) • Covered once every 2 years for all women • Annually for high risk beneficiaries. This includes: – – – – – – – – Childbearing age and any of the following apply: Cervical or vaginal cancer is/was present Abnormalities found in preceding 3 years Onset of sexual activity under age 16 Five or more sexual partners in a lifetime History of STI (including HIV) Fewer than 3 negative Pap smears within previous 7 years Absence of any Pap smear within previous 7 years • Both deductible and co-pays are waived under the Affordable Care Act (ACA) 26 Screening Pelvic and Clinical Breast Exam • In order for the screening Pelvic and Breast exam to be billable 7 of the following 11 exam elements must be documented: Inspection/palpation of breasts Digital rectal External genitalia Urethral meatus Urethra Bladder Vagina Cervix Uterus Adnexa/parametria Anus and perineum 27 Screening Pelvic and Clinical Breast Exam • HCPCS codes for reporting are: • Screening pelvic/clinical breast exam: o G0101 • Collection of screening pap smear: o Q0091 • Q0091, G0101, and/or problem-oriented E/M • ICD-9 CM codes: o V15.89 High risk o V72.31 Routine gynecological exam (only if comprehensive preventive service performed) o V76.2 Cervix V76.47 Vagina V76.49 Other sites 28 Additional E/M services • If the provider encounters a medical condition requiring treatment this may be billed using the appropriate level of E/M service. • Modifier 25 will be required to avoid payment bundling edits. • There should be distinct documentation as to the medical condition and the non-GYN diagnosis code should be documented and linked to the E/M • NOTE – Always be careful to link preventive codes with preventive diagnosis and E/M with clinical diagnosis codes, do not mix and match. 29 Mammography and Screening Guidelines • Screening mammography is a radiological procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer. • Mammograms are covered only when performed by an FDA certified screening center/suppliers. Interpretations are to be performed only by physicians who are included under the certification number of a certified screening center/supplier. • Medicaid only covers a mammography screening for the age range below: – 35 through 39 Baseline (only one allowed in this age group) – 40 and over Annual (11 months must have elapsed since the month of last screening) • NOTE: Months between mammographies are counted beginning with the month after the date of the examination 30 Hysterectomy Coding • Hysterectomy codes are reported using the range 58150 – 58294. • Use 59525 for a hysterectomy following a cesarean section. • The hysterectomy diagnosis must support the medical necessity for the hysterectomy. • Hysterectomy claims for recipients with a diagnosis of cervical dysplasia, pelvic pain, or pelvic inflammatory disease should be submitted with the following medical records: – history and physical, operative notes, pathology report, discharge summary and reports for treatments performed prior to the hysterectomy (such as laparoscopic procedures, D & Cs, conizations, or cervical biopsies). 31 Other Services • Sterilization procedures are coding using 58600 – 58671. • This procedure should be billed in addition to any other services performed, including OB care. • Diagnosis code for sterilization is V25.2 • Medicaid will not cover sterilization reversals. • Pessary fitting and insertion CPT code 57160 • Pessary supply non rubber HCPCS code A4562 and rubber A4561 32 Federal Sterilization Guidelines • The sterilization consent form is a federally mandated document. • Medicaid covers an individual to be sterilized only if the following guidelines listed in 42 CFR 441.253 are met: 1. The individual is at least 21 years old at the time the sterilization consent is obtained. 2. The individual is not a mentally incompetent individual. 3. At least 30 days, but not more than 180 days have passed between the date of informed consent and the date of the sterilization 4. Counseled in alternative methods of family planning and birth control. 5. Advised that the sterilization procedure is considered to be irreversible. 6. Provided a thorough explanation of the specific sterilization procedure to be performed 33 Birth Control Coding • Medicaid covers medically approved birth control methods such as Nuva Ring, Ortho Evra, emergency contraceptive counseling, contraceptive management procedures, and pharmaceuticals to prevent conception. • Birth control pills may be dispensed through a pharmacy. A recipient may receive up to a 3-month supply. • Diaphragm as a birth control method. A physician can fit the recipient and bill using CPT 57170 for diaphragm fitting. • The codes for IUD insertion correspond to the specific intrauterine device (IUD). • J7300 Para gard • J7302 Mirena • When billing for IUD insertion, CPT code 58300 is used. • The CPT code for removal of IUD is 58301, which includes an office visit. 34 Birth Control Coding • Depo-Provera contraceptive injection, J1055, is a covered service. Providers are advised to use an appropriate diagnosis code for contraceptive management. • The appropriate office visit code may be billed separately, unless the service is only the administration of the injectable drug in which case a provider can bill the injectable administration fee in addition to the Depo-Provera injection code. • Medicaid covers the removal of Norplant. The global period for CPT 11976 is one (1) pre-care day and ninety (90) postoperative days. 35 Questions • Contact Information – [email protected] – 615-504-6913 36 Thank you! Any Questions?