What to Do When a Pregnant Patient Has New Insurance

Counting the number of visits is key to proper billing of antepartum services.

Open enrollment means that you may have patients returning to your ob-gyn practice in various stages of their pregnancy with different insurance companies. CPT® clearly states that when all or part of the antepartum and/or postpartum patient care is provided (except delivery due to termination of pregnancy by abortion or referral to another provider for delivery), you should only report the antepartum codes.

This is easy to understand when the patient transfers to a new practice or the pregnancy does not develop to delivery. But what happens when the patient stays with the same provider the entire pregnancy, but her insurance company changes before she delivers? The complete care has been given by one provider or group practice, but two different insurance companies are now each responsible for payment for only a portion of the care.

Do you know what to do? Read on to find out.

Understand the Rules for Billing Antepartum Services

The most practical way to address this is to bill insurance ‘A’ for the total number of visits the patient was seen during her coverage period with that company. Then, bill insurance ‘B’ based on their preference of either reporting the global package code (e.g., 59400) with modifier 52 Reduced services or billing separately the number of antepartum services they were responsible for, followed by the appropriate delivery plus postpartum care code. Prepare for coding your ob-gyn’s services up to the date of the patient’s insurance
change depending on how many antepartum visits the physician provides — either one to three, four to six, or seven or more.

Counting 1, 2, 3 Means Office E/M Codes

Scenario: Your ob-gyn sees a pregnant patient for only one to three antepartum visits while covered by insurance A. How should you report this?

Solution: Report the appropriate evaluation and management (E/M) code for payment.

First visit: For the first obstetrics (ob) visit, don’t automatically look at 99214 Office or other outpatient visit for the evaluation and management of an established patient … 30-39 minutes of total time is spent on the date of the encounter. The patient could be new to the practice, or the first visit may meet level 5 criteria or only level 3 established visit criteria.

To confirm the E/M level, look to the entire code series (99202–99205 for new patients, 99211–99215 for established patients) as possible options, based on the physician documentation.

Tip: Advise the physician to document the first three ob visits in subjective, objective, assessment, and plan (SOAP) format. The ob flow sheet rarely documents enough elements to support anything higher than a level 2 E/M code.

Second and third visits: When Medicare and American College of Obstetricians and Gynecologists (ACOG) were developing the relative value units for antepartum care, the follow-up visit was estimated to be 99213 Office or other outpatient visit for the evaluation and management of an established patient … 20-29 minutes of total time is spent on the date of the encounter. This code is still your best bet for each of these visits in the absence of documented problems.

In some rare circumstances, however, such as when the patient has absolutely no problems during the visit, the documentation might only support 99212 Office or other outpatient visit for the evaluation and management of an established patient … 10-19 minutes of total time is spent on the date of encounter.

4–6 Visits Mean Antepartum Code

Scenario: Your ob-gyn sees a pregnant patient for four to six antepartum visits.

Solution: Report one unit of 59425 Antepartum care only; 4-6 visits, which represents the total services rendered by your ob-gyn.

Sometimes, a payer may instruct you to report a separate E/M service for the first ob encounter. Make sure to have this in writing; you would then need to meet the criteria of at least four additional visits to report 59425. The diagnosis code will be the same (Z34.0- Encounter for supervision of normal first pregnancy or Z34.8- Encounter for supervision of other normal pregnancy) unless the patient has any problems or complications.

7+ Visits May Mean Variation

Scenario: Your ob-gyn sees a pregnant patient for seven or more visits. The patient then transfers insurance.

Solution: Avoid reporting the global package codes since the patient will not have delivered during the time insurance ‘A’ is responsible for payment.

Option 1: For seven or more visits, CPT® has a specific code: 59426 Antepartum care only; 7 or more visits. In the absence of complications, report Z34.0- or Z34.8-. Otherwise, code for any documented complications during this time period, as appropriate.

Option 2: Some payers may ask you to report each visit separately. In such cases, ask the insurer to define “separately.”

This may mean reporting 59426 with the dates of the patient’s prenatal visits. Keep in mind that 59426 is valued based on the assumption that it includes a maximum of 10 visits. If the number of actual visits exceeds this, modifier 22 Increased procedural services might be appropriate, provided the documentation supports significant additional work.

WATCH OUT: Because you do not have a specific antepartum code for one to three visits, and must report E/M codes, payers sometimes will deny these claims and tell you to “include in the global.” Appeal these decisions. Explain to the payer that you cannot report a global code because the patient has changed insurance and you are billing them only for care they are responsible for.

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