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The following case study from the American Academy of Family Physicians American Family Physician magazine illustrates how various coding strategies can work with regard to intrapartum care:
Mary, a 22-year-old white female, goes to her family physician’s office for maternity care at six weeks gestation by dates and size. Prenatal care is routine, and the family physician provides one "new OB H&P" and 10 routine prenatal visits. Mary goes into spontaneous labor at 40 weeks and has mid-labor severe fetal distress requiring one hour of face-to-face and 30 minutes of non-face-to-face prolonged physician attendance by the family physician before a consultant performs a cesarean section. The family physician assists at surgery and then provides uncomplicated postpartum care for the mother and baby for three days.
Based upon these facts, coding options include:
— 59426 Antepartum care; 7 or more visits (plus Pap and lab)
— 99223 Initial hospital care, level 3
— 99354 Prolonged (face-to-face) services; first hour
— 99358 Prolonged (non-face-to-face) services; first hour
— 59514-80 Assist at cesarean section
— 59430 Postpartum care (plus Pap and lab)
— 99433 Subsequent hospital care, normal newborn
— 99238 Hospital discharge day management
— 99431 Normal newborn H&P
To show you how different carriers might interpret this scenario, here are some of the instructions from insurance companies instructing family physicians on how to bill for the evaluation and management of a maternity care patient who ultimately undergoes a cesarean, as described above.
• Blue Cross/Blue Shield of Oregon: According to this carrier, the scenario indicates that the family physician should bill for only antepartum care using the appropriate evaluation and management codes and, if performed, the assist at the cesarean section (59515-80). If the family physician will be following the patient for postpartum care, the physician should also code 59430.
• Lincoln National Life Insurance Company of Indiana: This company also suggests that the family physician bill for antepartum care using the appropriate evaluation and management codes for initial hospital care such as 99221 or 99222. Of course, if the family physician assists in the cesarean section, the family physician could also bill 59515-80.
• Oregon Office of Medical Assistance Programs: The family physician should code 59899 for unlisted procedure, maternity care, and delivery, as well as 59515-80 if the family physician assists in the cesarean section.
Note: If you compare the instructions of the insurance companies with the coding options discussed earlier, you would be undercoding the actual work performed. That’s another reason why it is vital that additional documentation such as a copy of the hospital admission note, intrapartum progress notes, or a written summary outlining the nature of services delivered be included with the claim.
Many practices find it effective to attach a face letter to the claim, acknowledging that the claim is unusual and asking claim processors to pay special attention to the claim. Here’s a sample letter prepared by American Family Physician magazine that you could use when corresponding with your insurer in situations such as this.
XYZ Insurance Company
To Whom It May Concern:
I am submitting a hard copy claim with this cover letter to inform you of the unusual circumstances associated with this patient.
I was the primary physician for [patient’s name], who had a normal pregnancy until she was admitted to the hospital. Up until that time, I followed and took care of all of her antepartum needs. Because of fetal distress, I was obligated to spend a prolonged time with the patient. A decision was made to perform a cesarean section, and a specialist was consulted. I assisted at the cesarean and performed all of the newborn and postpartum care.
This claim contains those codes that describe all of my antepartum, intrapartum, newborn care, and postpartum work-up. Appropriate documentation is also enclosed.
I would appreciate careful review of this claim. Should you have any questions, please do not hesitate to contact this office.
Note: Any claim submitted for unusual circumstances or services should always be submitted on hard copy and not electronically.