Coding Scenario

The following case illustrates how the coding strategies discussed above can work:

Mary, a 22 year-old white female 0-0-0, goes to her family physician's office for maternity care at 6 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 does a C-section. The family physician assists at surgery and then provides uncomplicated post-partum care for the mother and baby for three days.

Based upon this discussion paper, coding options for this example could be:

The payment policies for maternity care will vary by payer. Many of these policies may now be found on the payer's Web site and may include instructions for reporting unusual maternity care services.

Where payers do not provide guidance on how to report these services or deny your claims for services, it may be necessary to provide a letter explaining the services provided that were beyond those of the typical maternity care or delivery services.

To assist you with these situations, we have developed an example letter (1-page Word file; About Downloading) that may be used as a template for constructing a letter to your patient's insurance plan. The letter may be submitted as an attachment to your claim for services or submitted in appeal of denied charges. You might also choose to construct a similar statement to be submitted in the narrative field of your electronic claim. Claims containing a narrative statement are more likely to be sent to a person for review rather than being electronically adjudicated.