Obstetrics Coding and Documentation Reference Guide
This guide offers a comprehensive overview of coding and documentation practices in obstetrics, emphasizing the importance of accurate reporting for optimal reimbursement and compliance.
OB/GYN Medical Billing & Coding Alert
This guide offers a comprehensive overview of coding and documentation practices in obstetrics, emphasizing the importance of accurate reporting for optimal reimbursement and compliance.
Scope of Obstetric Care
It addresses various aspects of obstetric care, including antepartum, intrapartum, and postpartum services, as well as the nuances of global maternity care.
Global Maternity Care Reporting
Global maternity care reporting encompasses a range of services, such as:
- Antepartum Care
- Hospital Admission for Labor and Delivery
- Labor Management (including fetal monitoring)
- Uncomplicated Postpartum Care (for up to six weeks following delivery)
A global charge is applicable when all maternity-related services are provided by the same physician or within the same group practice. Individual Evaluation and Management (E&M) codes should not be utilized for maternity visits, as prenatal care is included in the global reimbursement and not separately reimbursed.
The following codes are designated for global maternity services:
Routine Obstetric Care Codes
-
CPT Code 59400
Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care. -
CPT Code 59510
Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care. -
CPT Code 59610
Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care after a previous cesarean delivery. -
CPT Code 59618
Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care following an attempted vaginal delivery after a previous cesarean delivery.
Separately Billed Prenatal, Delivery, and Postpartum Services
It may be necessary to bill for prenatal, delivery, and postpartum services separately rather than submitting a global maternity claim. The following are instances when this is appropriate:
- The member’s coverage starts after the pregnancy has begun.
- The member’s coverage ends before the delivery.
- The pregnancy does not result in a delivery.
- Another provider in a different location takes over care before the completion of global services.
- A change in the member’s benefits occurs during the pregnancy.
Billing Guidelines for Maternity Services
Antepartum Care
- 1-3 visits: Use Evaluation and Management (E&M) Codes.
- 4-6 visits: Use CPT Code 59425.
- 7 or more visits: Use CPT Code 59426.
Postpartum Care
Postpartum care only: Use CPT Code 59430
Note: When providers from different practices handle different parts of maternity care, such as prenatal or postpartum services, the delivering provider can submit claims using the appropriate antepartum/postpartum codes based on the number of visits.
CPT Coding for Maternity-Related Services
CPT codes are essential for accurately reporting and billing maternity services based on the specific care provided, whether routine care, delivery only, or postpartum care.
Routine Obstetric Care (Antepartum, Delivery, and Postpartum)
- 59400: Routine care, including antepartum, vaginal delivery (with/without episiotomy or forceps), and postpartum care.
- 59510: Routine care, including antepartum, 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 care following an attempted vaginal delivery after a previous cesarean, including antepartum, cesarean delivery, and postpartum care.
Delivery Only
- 59409: Vaginal delivery only (with/without episiotomy or forceps).
- 59514: Cesarean delivery only.
- 59612: Vaginal delivery only, after a previous cesarean (with/without episiotomy or forceps).
- 59620: Cesarean delivery only, following attempted vaginal delivery after a previous cesarean.
Delivery and Postpartum Care
- 59410: Vaginal delivery (with/without episiotomy or forceps) with postpartum care.
- 59515: Cesarean delivery with postpartum care.
- 59614: Vaginal delivery (with/without episiotomy or forceps) after a previous cesarean, with postpartum care.
- 59622: Cesarean delivery with postpartum care, following attempted vaginal delivery after a previous cesarean.
Antepartum and Postpartum Care Only
- 59425: Antepartum care only, 4-6 visits.
- 59426: Antepartum care only, 7 or more visits.
- 59430: Postpartum care only.
Obstetrics Coding and Documentation Guide
It is essential to fully understand the correct guidelines before proceeding with coding and documentation to ensure accuracy and compliance. Proper knowledge of the rules helps prevent errors and guarantees that claims are submitted correctly. Here is the documentation guide given below:
Quality Reporting for Maternity Care
To comply with Healthcare Effectiveness Data Information Set (HEDIS) guidelines, Blue Cross and Blue Shield of Alabama require the submission of specific claims related to maternity care and the global billing claim. These claims must include:
Date of First Prenatal Visit
Submit a claim reflecting the date of the first prenatal care visit. Use the following CPT Category II codes:
- 0500F: For the initial prenatal care visit.
- 0501F: For documentation of a prenatal flow sheet during the first visit.
Date of Postpartum Visit
The postpartum visit should occur 4-6 weeks after delivery. Submit a claim for this visit using the following:
- CPT II Code 0503F: For postpartum care.
- ICD-10 Code Z39.2: For routine postpartum follow-up.
Guidelines for Maternity Diagnosis Coding
For diagnosis coding, use the ICD-10-CM code range O00-O9A, prioritizing these codes over others. Additional codes from other categories can be used alongside maternity codes to clarify the patient's condition further. If the provider indicates that the pregnancy is incidental to the visit, use ICD-10-CM code Z33.1 (pregnancy state, incidental) instead of codes from the O00-O9A range. Document the treated condition and confirm that it does not affect the pregnancy.
Obstetrics Principal Diagnosis for Routine Prenatal Visits
For routine outpatient prenatal visits without complications, use a code from category Z34 (Encounter for supervision of normal pregnancy) as the primary diagnosis. These codes should not be used in conjunction with codes from the O00-O9A category.
Prenatal Outpatient Visits for High-Risk Patients
For outpatient routine prenatal visits involving high-risk pregnancies, you should use an ICD-10-CM code from category O09 (supervision of high-risk pregnancies) as the primary diagnosis. Additional secondary codes can be included to provide more detail about the patient's condition.
Episodes Without Delivery
In cases where no delivery occurs, the primary diagnosis should reflect the main complication of the pregnancy that led to the visit. If multiple complications are present, any of the complication codes can be prioritized based on the treatment or monitoring provided.
When Delivery Occurs
When a delivery takes place, the primary diagnosis must reflect the main circumstance or complication related to the delivery. In cases of cesarean sections, the principal diagnosis should be the condition that led to the patient's admission for the procedure.
Normal Delivery
For a full-term, uncomplicated delivery, you should assign ICD-10-CM code O80. This code applies when a patient is admitted for a normal delivery and gives birth to a single, healthy infant without any complications before, during, or after the delivery. ICD-10-CM code O80 is always the principal diagnosis and should not be combined with other codes that describe any current complications. Additionally, ICD-10-CM code Z37.0, indicating a single live birth, is the only delivery outcome code that should accompany ICD-10-CM code O80.
Outcome of Delivery
When delivery occurs, it is essential to include a code from the ICD-10-CM category Z37, which indicates the delivery outcome, on every maternal record. However, these codes should not be used on any subsequent maternal records or the newborn's records.
Claims Submission Additional Tips
- The initial visit to confirm pregnancy is not included in global maternity care services and verification of benefits will determine the member's reimbursement responsibility.
- A global charge should be applied for a single physician or multiple physicians within the same group (identified by the same tax identification number), covering all aspects of the patient's maternity care, which includes four or more antepartum visits, delivery, and postpartum care.
- Antepartum services, such as laboratory tests (excluding dipstick urinalysis), diagnostic ultrasounds, amniocentesis, cordocentesis, chorionic villus sampling, fetal stress tests, and fetal non-stress tests, are not considered part of global maternity services and should be billed separately.
Services Unrelated to Pregnancy in Global Maternity Care
Reporting Services Unrelated to Pregnancy: Any services a physician provides rendering global maternity care unrelated to the pregnancy must be reported separately. Use the appropriate inpatient or outpatient Evaluation and Management (E&M) codes and the corresponding diagnosis code for the unrelated condition. The diagnosis must reflect that the service is separately identifiable.
Surgical Complications: Any services related to surgical complications should also be billed separately. Physicians are encouraged to refer to the latest version of the CPT manual to identify the appropriate surgical codes.
Diagnostic Ultrasounds: Diagnostic ultrasounds conducted during pregnancy are reimbursed separately from the global maternity care fee.
Referral to a Perinatologist: If a member is referred to and evaluated, this service should be billed using an E&M consultation code. It is essential to include the diagnosis code that warranted the referral; do not use maternity health status codes, as global maternity care may cover these.
Complications of Pregnancy: Complications that arise during pregnancy, which are distinct from the normal course of pregnancy and may jeopardize the mother’s health or the viability of the infant, require treatment before the pregnancy reaches full term. These complications should be appropriately documented and coded.
Obstetrics Coding and Documentation Reference Scenarios
Maternity Care Provided by Two Different Physicians in Separate Groups
When two physicians from separate groups provide maternity care, the billing process differs based on their specific roles. For instance, if Dr. A is responsible solely for antepartum and/or postpartum care without performing the delivery, they should submit the relevant CPT codes specifically for those services. Meanwhile, Dr. B, who performs the delivery, should submit the appropriate CPT code for the delivery procedure.
In this scenario, neither provider should use a global CPT code, as the services provided do not fall under a single global maternity care package.
Maternity Care Provided by Two Different Physicians in the Same Group
When two providers deliver maternity care services in the same location or group, they should submit a single claim using the appropriate global maternity CPT code. Filing two separate claims for each provider is unnecessary and not permitted, as the care is provided under the same organizational umbrella.
Repair of Fourth-Degree Laceration During Delivery
In a scenario where Dr. A handles the vaginal delivery, and Dr. B performs the repair of fourth-degree lacerations to the cervix, the claims should be submitted in a specific order. First, Dr. A should file a claim for the global maternity services associated with the vaginal delivery. Subsequently, Dr. B should submit a separate claim for the repair of the fourth-degree laceration, as this service is considered distinct from the maternity care provided during the delivery.
Obstetrics Documentation Requirements Tips
We provide essential documentation guidelines for maternity care, detailing conditions due to complications in both outpatient and inpatient settings when applicable. These requirements ensure comprehensive patient records, facilitating effective management of obstetric care.
Required Documentation for Maternity Care
To ensure comprehensive maternity care documentation, the following details should be included:
- Gestational Information
- Indicate the patient's pregnancy week and day (e.g., 30 weeks, 3 days).
- Specify whether it is the patient's first or subsequent pregnancy.
- Complications and Risks
- Document any complications that have developed during the pregnancy.
- Clearly state the reasons why the pregnancy is classified as high-risk (e.g., advanced maternal age, poor prenatal history).
- Pre-existing Conditions
- Include any underlying or pre-existing conditions affecting the pregnancy, such as hypertension, diabetes, or anemia.
- Detail the management of gestational diabetes, specifying whether it is controlled through diet, insulin, or other means.
- Fetal Considerations
- Describe any fetal conditions that impact the management of the pregnancy, including the trimester of concern.
- For pregnancies with multiple fetuses, note any conditions affecting some or all of the fetuses and assign an identification number or letter to each fetus (e.g., 1-8, A-H).
- Group B Streptococcus (GBS) Status
- Record the results of the patient's group B streptococcus screening.
- Specify if the patient has an active GBS infection or if she is a carrier.
Conditions Due to Complications in Outpatient Setting (When Applicable)
- Document if the patient is being seen to supervise a normal pregnancy.
- Include the gestational week(s) and day(s) (e.g., 30 weeks, 3 days).
- Note any complications that develop during the visit.
- Specify whether this is the patient's first or subsequent pregnancy.
Conditions Due to Complications in Inpatient Setting (When Applicable)
- Document conditions requiring admission.
- Record gestational week(s) and day(s) at the time of admission and throughout the hospital stay (e.g., 30 weeks, 3 days).
- Note any complications that develop during the hospital stay (e.g., patient admitted at 35 weeks, 3 days; developed preeclampsia on day 3 of stay).
- Specify if delivery occurs during the admission.
- Indicate if the delivery is normal, full-term, and uncomplicated.
- Document any delivery complications that arise.
- Record the delivery outcome.
- Note the number of fetuses.
- Specify the living status of each fetus (e.g., liveborn vs. stillborn).
- Identify the location of delivery (e.g., hospital, car).
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