From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing:Obstetrics Coding Speaker:Laurie Beauchamp Date:22 March 2007 Time:

2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives Define Global to the MHS Coding Guidelines – Civilian – MHS Discuss Diagnosis Coding – Uncomplicated – Complicated Show what is – Routine – Non-routine Discuss postpartum care – Routine – Non-routine

2007 UBO/UBU Conference From Registration to Accounts Receivable 3 Civilian vs. MHS Coding Let’s talk about civilian coding first – Global codes (Inpatient and outpatient combined) – Routine OB including antepartum, vaginal delivery, and postpartum care – Routine OB including antepartum, C-section, and postpartum – Routine OB including antepartum, VBAC, and postpartum – These are global codes and cover the first visit through to the post-partum – They get billed one-time by the physician after delivery

2007 UBO/UBU Conference From Registration to Accounts Receivable 4 Civilian Unbundling Coding If 3 or fewer visits, the provider codes E/Ms based on documentation – 4-6 routine OB outpatient visits – 7-13 routine OB outpatient visits – Postpartum care only – This happens when the patient changes providers or moves during her pregnancy – Vaginal delivery only – C-section delivery only – Vaginal after previous Cesarean delivery only – This happens when the patient shows up at the ER in labor

2007 UBO/UBU Conference From Registration to Accounts Receivable 5 MHS Coding Guidance Category II CPT Codes – 0500F – Initial prenatal care visit – 0501F – Do not use – 0502F – Subsequent prenatal care visit – 0503F – Postpartum care visit Use this code if delivery and postpartum visit are performed by the same group practice – – Postpartum care visit Use this code if the antenatal care or delivery were done elsewhere

2007 UBO/UBU Conference From Registration to Accounts Receivable 6 “And The Magic Happens” Work with your systems people – For 2569 or OHI patients, generate a monthly ad hoc that reports: Pt name, All encounters with 0500F, 0501F, 0503F, Date of last menstrual period (LMP) – When you see a patient with a 0503F or 59430, that means there is an outcome of pregnancy Count up all the 0500F, 0501F, and 0503F – For 4-6 encounters, bill – For 7+ encounters, bill – If fewer than 4 encounters, ask coders to recode the encounters based on documentation for regular E&M, then bill those – The encounter coded with will generate its own bill

2007 UBO/UBU Conference From Registration to Accounts Receivable 7 ICD Coding Guidance General Rules for Obstetric Cases – Codes from Chapter 11 and sequencing priorities Chapter 11 ( ) of ICD-9 includes complications of pregnancy, childbirth, and the puerperium – These take precedence over other chapters of codes when the encounter is pregnancy-related All conditions in pregnancy should be coded as complications unless the privileged provider documents otherwise Providers rarely state the problem is not affecting the pregnancy. So use of V22.2 is not common – Assuming will only lead to complications and eventually coding errors —Continued—

2007 UBO/UBU Conference From Registration to Accounts Receivable 8 ICD Coding Pay special attention to fifth digits for codes and These fifth digits denote the episode of care – 0 – Unspecified (Rarely appropriate) – 1 – Delivered with/without mention of antepartum condition – 2 – Delivered with mention of postpartum complication Verify with supervisor before using these fifth digits in the outpatient clinic: – 3 – Antepartum condition or complication – 4 – Postpartum condition or complication

2007 UBO/UBU Conference From Registration to Accounts Receivable 9 The First Listed Diagnosis for Ante Partum Routine outpatient prenatal visits – Code V22.0 (first pregnancy) or V22.1 (subsequent pregnancy) should be assigned – May only be assigned when no complications are present Do Not use in conjunction with Chapter 11 codes Prenatal outpatient visits for high-risk patients – Select a code from V23.x (supervision of high-risk pregnancy) – Should be first-listed – Secondary Chapter 11 codes may be assigned as appropriate

2007 UBO/UBU Conference From Registration to Accounts Receivable 10 Complications Fetal conditions that affect management of the mother – Assigned when the fetal condition is actually responsible for modifying the management of the mother (i.e., by requiring diagnostic studies, additional observations, special care, or termination of pregnancy) Current conditions complicating pregnancy – 648.x series For patients that have current conditions when the condition affects the management of the pregnancy – Use additional codes from other chapters to identify the conditions, as appropriate Gestational diabetes – Coded when patients were not diabetic prior to the pregnancy – 648.8x should be assigned

2007 UBO/UBU Conference From Registration to Accounts Receivable 11 Routine Obstetric Care General CPT Coding Rules – For obstetrical coding within the MHS, the following are listed as routine obstetrical care services Monthly visits up to 28 weeks Bi-weekly visits up to 36 weeks Weekly visits until delivery The following services are bundled into all routine OB care visits (CPT) – Pap smear at first prenatal visit – Screening for hypertension disorders – Breast feeding education – Exercise during pregnancy – Influenza vaccine (season-related, 6-20 weeks)

2007 UBO/UBU Conference From Registration to Accounts Receivable 12 Coding for Complications with E/Ms General Evaluation and Management Coding Rules – Most routine OB care visits will be assigned E/M code – Medical problems complicating obstetric management may require additional resources and should be identified by using the E&M codes in addition to those codes for maternity – Do not append modifier 25 to the E/M code when the only CPT code reported is (050xF) Patients with E/M codes will typically have diagnosis code(s) from Chapter 11 assigned

2007 UBO/UBU Conference From Registration to Accounts Receivable 13 Examples of Complications – Pre-existing diabetes – Gestational diabetes mellitus (GDM) – Pregnancy-induced hypertension or pre- eclampsia – Fetal anomaly or abnormal presentation (older than or equal to 36 weeks) – Multiples (i.e. twins) – Placenta previa – Hypertension – HIV (or abnormal screen) – Advanced maternal age (35 yrs or older at EDC) – Young maternal age (less than 16 yrs at EDC) – Past complicated pregnancy – Prior preterm delivery – Prior preterm labor requiring admission (e.g., early cervical change) – Intrauterine fetal demise – Prior cervical or uterine surgery – Fetal anatomic abnormality – Abnormal fetal growth – Preterm labor requiring admission – Abnormal amniotic fluid – Bleeding – Anemia – Recurrent urinary tract infections or stones – Substance use disorders – Abnormal maternal triple screen **Please note this list is not all-inclusive, and is only a guide**

2007 UBO/UBU Conference From Registration to Accounts Receivable 14 Use Additional CPT Codes Some procedural Services should be reported separately even when performed during a routine visit. This list is not all inclusive but includes common procedures performed – Ultrasound – Insertion of a cervical dilator – Echocardiography – External cephalic version (done in the clinic) – Fetal biophysical profile – Administration of Rh immune globulin – Amniocentesis – Fetal Non-stress Test (NST)

2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Uncomplicated Postpartum Care Routine postpartum encounter with no complications Postpartum care and examination – V24.1 (Primary Dx Only) Supervision of lactating mother – V24.2 (Primary Dx Only) Routine postpartum follow-up

2007 UBO/UBU Conference From Registration to Accounts Receivable 16 Postpartum Diagnosis Coding Selecting the first-listed – Postpartum – Immediately following delivery and continues for six weeks following delivery – Postpartum complication – any complication occurring in the postpartum period Use Chapter 11 codes You may also use Chapter 11 codes for postpartum after the completion of six weeks when the provider documents the condition is pregnancy related Late effects of complication of pregnancy (677) – Used when an initial complication of pregnancy develops a sequelae requiring care or treatment at a future date – May be used at any time after the initial postpartum period – Should be sequenced following the code describing the sequelae or complication

2007 UBO/UBU Conference From Registration to Accounts Receivable 17 Summary We have covered: – Category II CPT Codes MHS Coding Guidance – ICD Coding Guidance – EM Coding Guidance – From pregnancy testing to postpartum care

2007 UBO/UBU Conference From Registration to Accounts Receivable 18 Q&A Questions?

2007 UBO/UBU Conference From Registration to Accounts Receivable 19 Contact Information Laurie Beauchamp, CPC, CCS-P DSN from CONUS HQ USAFE/SG UNIT 3050 BOX 130 APO AE