How to Recoup Ethical Extra Reimbursement for Pregnant Diabetic Patients?
Learn the differences between pre-existing and gestational diabetes in pregnancy, coding guidelines, and steps for proper billing and documentation in OB/GYN care.
OB/GYN Medical Billing & Coding Alert
Differentiate between diabetes that exists before pregnancy and gestational diabetes.
It is important to understand that a pregnant patient with diabetes needs care beyond the standard global package, requiring a higher level of management expertise. But does your patient payer?
Proper documentation is essential to demonstrate that your OBGYN is actively managing the patient’s diabetes.
Let's find out the steps to follow:
Step 1: Highlight the Distinction
The primary distinction between a diabetic and non-diabetic OB/GYN patient is that the diabetic patient must maintain ongoing communication with her physician.
Pregnant diabetic patients generally fall into one of these categories, each necessitating significant physician oversight:
- Pre-existing diabetes type I or II, controlled: These patients are generally easier for OBGYNs to monitor compared to those with uncontrolled diabetes. Since they are already accustomed to managing their condition, they can consistently maintain their insulin levels through diligent disease management.
- Pre-existing diabetes type I or II, uncontrolled: Patients unable to manage their diabetes with medication and diet will require added monitoring and guidance. Pregnant women with uncontrolled diabetes often have larger babies, making cesarean deliveries more likely.
- Gestational diabetes, controlled or uncontrolled: Gestational diabetes frequently remains undetected until later in the pregnancy. Patients newly diagnosed with diabetes need comprehensive education and guidance to establish a proper care regimen throughout their pregnancy.
Step 2: Establish the Need for Additional Office Visits
Securing reimbursement for additional office visits for diabetic OB/GYN patients can be challenging.
Here’s why: Pregnant diabetic patients need more frequent monitoring due to heightened risks for both mother and fetus. Generally, the obstetrician sees the patient every two weeks for the first seven months and then more frequently during the last two months. In some cases, the patient may even go to the hospital every other day for a fetal non-stress test (59025-26, Fetal non-stress test; professional component) in the final months.
Key point: The global obstetric package does not cover office visits for diabetes management, so these should be reported as separate evaluation and management (E/M) visits. For example, 99212 is typically used for these non-global E/M visits. However, if billing for a higher-level E/M, such as 99213 or 99214, additional medical justification is necessary for the higher levels and increased visit frequency.
One approach: Some OBGYNs, particularly those handling high-risk cases, negotiate high-risk global packages with insurers. This allows for an all-inclusive global fee, which covers extra visits and reduces the need to justify individual E/M charges.
Step 3: Addressing the Challenge of Additional Testing
While additional office visits may be accounted for, managing a diabetic pregnancy often requires extra testing.
These tests commonly include:
- Hemoglobin A1C (82820): Assesses hemoglobin-oxygen affinity.
- Alpha-fetoprotein (AFP) (82105 for serum or 82106 for amniotic fluid): Screens for potential fetal issues.
- Ultrasound (76805-76828): Used frequently, depending on the method and approach.
- Electronic fetal monitoring (59051): For non-attending physicians who provide interpretation and documentation. (For attending physicians, include this in the global package.)
- Fetal non-stress test (59025): Checks fetal well-being.
- Spina bifida screening (such as 82013, Acetylcholinesterase; 82105 or 82106): Detects potential neural tube defects.
Here’s the issue: Securing additional reimbursement for these tests can be complicated due to diagnosis coding challenges. ICD-10 includes a diabetes-with-pregnancy code. However, even with an additional code specifying the diabetes type, some payers may deny coverage for extra services solely because a pregnancy code is used.
Step 4: Understand Your ICD-10 Coding Choices
ICD-10 offers specific codes for gestational diabetes under category O24.4- (Gestational diabetes mellitus). However, remember that these codes should not be used if the patient has only had a one-hour glucose tolerance test (GTT) with abnormal results. A diagnosis of gestational diabetes requires an abnormal result from a three- or four-specimen GTT. Additionally, ICD-10 codes for gestational diabetes are detailed enough to indicate insulin or hypoglycemic drug use, so you don’t need to add a separate code for long-term insulin use.
The codes are as follows:
- O24.410 – Gestational diabetes in pregnancy, diet-controlled
- O24.414 – Gestational diabetes mellitus in pregnancy, insulin controlled
- O24.415 –Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs
Gestational diabetes mellitus in pregnancy, controlled by oral antidiabetic drugs
- O24.419 – Gestational diabetes mellitus in pregnancy, unspecified control
For gestational diabetes during childbirth:
- O24.420 – Gestational diabetes mellitus in childbirth, diet controlled
- O24.424 – Gestational diabetes mellitus in childbirth, insulin controlled
- O24.425 – Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs
Gestational diabetes mellitus in childbirth, controlled by oral antidiabetic drugs
- O24.429 – Gestational diabetes mellitus in childbirth, unspecified control
For gestational diabetes in the puerperium:
- O24.430 – Gestational diabetes mellitus in the puerperium, diet controlled
- O24.434 – Gestational diabetes mellitus in the puerperium, insulin controlled
- O24.435 – Gestational diabetes mellitus in puerperium, controlled by oral hypoglycemic drugs
Gestational diabetes mellitus in puerperium, controlled by oral antidiabetic drugs
- O24.439 – Gestational diabetes mellitus in the puerperium, unspecified control
Other relevant codes for abnormal glucose complications include:
- O99.810 – Abnormal glucose complicating pregnancy
- O99.814 – Abnormal glucose complicating childbirth
- O99.815 – Abnormal glucose complicating the puerperium
Step 5: Applying Diagnosis Codes with CPT Codes
Wondering how to link diagnosis codes to your CPT codes correctly? Here’s a practical example.
Example: An OBGYN performs a detailed ultrasound on a pregnant patient with diet-controlled gestational diabetes. For this service, report 76811 (Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation, including detailed fetal anatomic examination, transabdominal approach; single or first gestation).
Link this procedure with O24.410 to indicate that the patient has gestational diabetes managed by diet.
BillingFreedom is the Top Choice for OBGYN Medical Billing Services
BillingFreedom stands as the premier OBGYN medical billing services provider, equipped to handle the intricate billing needs for diabetic and high-risk pregnancies. With a deep understanding of the distinctions between gestational and pre-existing diabetes, we ensure accurate coding and secure reimbursement for additional office visits and specialized testing.
Our expertise in ICD-10 codes and high-risk global packages allows OBGYN practices to focus on patient care while we seamlessly manage complex billing requirements. At BillingFreedom, we prioritize precise documentation and proactive negotiation with payers to maximize revenue for your practice.
Trust us to navigate these unique billing challenges and provide an unparalleled level of support tailored to OBGYN specialties.
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.
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