Prevent Mistakes When a Pregnant Patient Switches Insurance Prior to Delivery
Pregnant Patient Switching/Changing Her Insurance Company During Her Global Period; what to do?
OB/GYN Medical Billing & Coding Alert
Pregnant Patient Switching/Changing Her Insurance Company During Her Global Period; what to do?
What if the patient stays with one provider during her entire pregnancy, but she changes the insurance company before she delivers?
In this case, it is clear that complete care has been provided by a single provider or group practice, making them eligible to receive payment for the services rendered. However, since the patient changed her insurance company during her pregnancy, two different insurance companies are now involved. Each insurer is responsible for covering the portion of care provided during the period in which they were active, ensuring that both are eligible for payment for their respective portions of care.
For the visits covered by the first insurance (Insurance A), bill them for the total number of visits during their coverage period. For the new insurance (Insurance B), you have two options. You can either bill using the global package code (like 59400) with a modifier 52 to indicate reduced services or separately for the antepartum care covered by Insurance B, plus the delivery and postpartum care.
Understanding the rules for billing antepartum care separately is crucial to ensure proper reimbursement.
When coding for OB services up to the date of a patient’s insurance change, you’ll need to determine the number of visits the physician provided:
- One to Three Visits
- Four to Six Visits
- Seven or More Visits
Let’s explain with appropriate scenarios and their solutions with reference to accurate coding..
1-3 Visits Mean Office E/M Codes
Scenario: If your OB provides care to a pregnant patient for just one to three visits, how should this be billed?
Solution: In this case, you should use the corresponding office or outpatient evaluation and management (E/M) codes, such as 99211 through 99215, depending on the level of service for each visit. This approach allows accurate billing for the specific care provided during these initial appointments.
First Visit: When coding for the first OB visit, don’t automatically default to a level-four established patient visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making). When using time for code selection, 30-39 minutes of total time is spent on the encounter date.
You won't have a predetermined E/M code for the patient's first visit at this stage. The patient could either be new to the practice or, if established, the visit might even meet the criteria for a level-five visit. Hence, you should review the full range of E/M codes—99202-99205 for new patients and 99211-99215 for established patients. The selection should be based on the physician's documentation, ensuring that it accurately reflects the complexity and nature of the visit.
Second And Third Visits: For the second and third OB visits, your coding options are more straightforward. Medicare and the American College of Obstetricians and Gynecologists (ACOG) determined that a typical follow-up visit should be coded as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter).
In the absence of any documented complications or additional issues, 99213 is usually the appropriate code for these follow-up visits. This code reflects the standard level of care expected during these routine appointments.
Heads up: In rare situations where the patient has no issues or complications during the visit, the documentation might only support reporting 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter).
If the patient’s pregnancy is uncomplicated, you would use the diagnosis codes Z34.0-_ (Encounter for supervision of normal first pregnancy) or Z34.8- (Encounter for supervision of other normal pregnancy) to reflect the routine nature of the visit.
Watch out: There is no specific code for one to three visits, so you must use E/M codes. However, some payers may deny these claims, suggesting that the charges should be included in the global fee. In such cases, you will need to appeal these denials.
When appealing, explain to the payer that a global code cannot be used because the patient has switched insurance. Clarify that you are billing only for the care provided by your providers, which falls outside the scope of the global fee. Provide documentation to support that these visits were billed separately due to the insurance change and were not included in any global fee.
4-6 Visits Mean Antepartum Code
Scenario: Your OB sees a pregnant patient for four to six visits. How should you report this?
Solution: For four to six visits, you should refer to the antepartum care section of your coding manual. Use code 59425 (Antepartum care only; 4-6 visits) to represent the total care provided by your OB. This means you will report only one unit of this code.
In rare instances, some payers may require a separate E/M code for the initial OB visit. If this applies, obtain written confirmation from the payer and ensure you meet the criteria for at least four additional visits before using 59425.
Note: The diagnosis codes will generally be Z34.0- (Encounter for supervision of normal first pregnancy) or Z34.8- (Encounter for supervision of other normal pregnancy) unless there are complications or problems with the pregnancy.
7+ Visits May Mean Variation
Scenario: If your OB sees a pregnant patient for seven or more visits and the patient subsequently changes insurance, how should you report this?
Solution: In this scenario, your coding options will vary, but you should avoid reporting global package codes. Since the delivery occurred after the patient’s insurance coverage with Insurance A ended, the global codes (59400-59622) are not applicable. Instead, bill for the antepartum visits provided during Insurance A’s coverage period and follow up with Insurance B for the delivery and any remaining postpartum care.
Option 1: For seven or more visits, use CPT code 59426. This code covers seven or more visits during the antepartum period. Include appropriate diagnosis codes such as Z34.0-, Z34.8-, or codes for any documented complications encountered during this time. If complications arise, update the diagnosis code from routine pregnancy supervision to reflect the specific issues addressed during the antepartum care.
Option 2: Some insurers may require you to report each visit separately. It’s a good practice to confirm with the insurer what they mean by “separate” reporting.
In some cases, “separate” may involve submitting CPT code 59426 along with a detailed list of the visit dates. Since 59426 assumes a maximum of 10 visits and covers a broad scope, if the actual number of visits exceeds this, consider using modifier 22 (Increased Procedural Service) if the additional work is well-documented. This is especially relevant as 59426 is a “surgical” code.
While it’s unlikely, some payers might require reporting the appropriate E/M code for each visit. Always verify the specific requirements with the payer to ensure compliance.
Why Choose BillingFreedom for OB-GYN Billing?
At BillingFreedom, we excel in navigating the complexities of OB-GYN billing, ensuring precise and efficient claims management. We expertly handle coding challenges for patients with multiple antepartum visits and insurance changes using appropriate CPT codes, such as 59426 for seven or more visits. We stay vigilant about payer requirements, whether reporting visits separately or utilizing modifiers like 22 for additional services. Our in-depth understanding of the nuances in OB-GYN billing, including diagnosis coding and procedural adjustments, ensures optimal reimbursement and compliance.
Trust BillingFreedom for reliable, expert billing services according to your practice’s needs. For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472. Your financial tranquility is our priority!
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