Double Trouble: How to Code NSTs and BPPs for Twin Pregnancies
When managing a twin pregnancy in your OB/GYN practice, it's crucial to accurately document the increased workload associated with this type of gestation.
OB/GYN Medical Billing & Coding Alert
Utilizing single-pregnancy codes for multiple gestations can lead to financial losses for your practice.
Fortunately, CPT provides specific codes to reflect the additional diagnostic procedures required for twin pregnancies. However, a common issue is that many payers do not acknowledge the additional complexity and effort involved. Precise coding practices and effective communication with payers are essential to address these challenges.
Melanie Witt, RN, MA, an independent coding consultant based in Guadalupita, New Mexico, highlights the importance of accurate coding and payer interaction to ensure proper reimbursement for the extra work involved in managing twin pregnancies.
Obstetricians and maternal-fetal specialists often spend more time overseeing twin pregnancies than single pregnancies and may need to conduct extra diagnostic tests to monitor both fetuses.
Unfortunately, physicians may not receive appropriate compensation for this added complexity due to reimbursement policies or coding errors.
For instance, CPT provides a specific code for a complete ultrasound of multiple gestations (Code 76810: "Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation, after the first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation [List separately in addition to code for primary procedure]"); other services are reported with codes designed for a single pregnancy.
What About NSTs and BPPs?
When it comes to billing for non-stress tests (NSTs) and biophysical profiles (BPPs) in cases of twin pregnancies, many practitioners wonder if they can bill for these procedures separately for each fetus.
The code for an NST, 59025, specifies the service for a single fetus. However, in the case of twins, where two NSTs are performed, once for each fetus, there are a few coding options to consider:
Bill Each NST Separately
The most precise method for billing NSTs in twin pregnancies is to submit each test separately, according to Witt. There are two approaches to accomplish this:
- Single-Line Approach: Report a quantity of two for code 59025 (linked to the diagnosis of why the NST was medically indicated and the presence of twins, O30.0- (Twin pregnancy).
- Two-Line Approach: List code 59025 twice on the claim. The second entry may require a modifier 51 (Multiple Procedures) to indicate that the second test is subject to discounting. This method aligns with standard coding practices for multiple procedures, as NSTs are categorized similarly in the CPT manual.
Append Modifier 22
Another option is to append modifier 22 (Increased Procedural Services) to indicate that the services provided were more extensive or complicated than usual, according to Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.
Cobuzzi advises including a cover letter with the claim detailing why additional reimbursement is being requested. This can help clarify the extent of the services provided and may reduce the likelihood of claim denials.
Modifier 51 for BPPs May Not Be Necessary
For coding biophysical profiles (BPPs), you can use either the single-line or two-line approach similar to NSTs.
When performing and documenting two BPPs for twins, code both procedures. Using the single-line approach, report code 76818 (Fetal biophysical profile with non-stress testing) with a quantity of two. Alternatively, for the two-line approach, list code 76818 twice.
Unlike surgical codes, radiologic codes typically do not require modifier 51 (Multiple Procedures) for the second BPP due to many payers' less frequent multiple procedure discounting. However, it is advisable to verify with your payer to prevent any payment issues.
Common Billing Mistakes to Avoid for NSTs and BPPs
Some coders have suggested using modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional) or modifier 59 (Distinct Procedural Service) for billing multiple NSTs. However, Witt says this approach is inaccurate.
- Modifier 76 is intended for subsequent procedures on the same patient. Since NSTs performed on different fetuses are not repeats of the same procedure, this modifier does not apply. Each NST is for a different fetus, not a repeat of the same service.
- Modifier 59 indicates that a procedure is distinct or independent from other services performed on the same day. An NST is not considered part of a global obstetric service or an integral part of another procedure. Modifier 59 is generally used with CPT codes that include "separate procedure," which does not apply to code 59025.
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