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:
Coding Scenario
| 59426 | Antepartum care; 7 or more visits (plus pap and lab). |
| 99223 | Initial hospital care - level 3. |
| 99356 | 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. |
Coding Instructions: Insurance Carriers
To show you how divergently various carriers interpret the above scenarios, the following are some of the instructions received by the AAFP from insurance companies instructing family physicians on how to bill for the evaluation and management of an maternity care patient that ultimately undergoes a C-Section (as described above):
1. Blue Cross/Blue Shield of Oregon.
In a March 3, 1992, letter, they suggest 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.
2. Lincoln National Life Insurance Company of Indiana.
They also suggest (February 14, 1992) that the family physician bill for antepartum care using the appropriate evaluation and management codes, 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.
3. Office of Medical Assistance Programs (Oregon).
They suggest (March 20, 1992) that the family physician code 59899 for unlisted procedure, maternity care and delivery, as well as 59515-80 if they assist in the Cesarean Section.
In a March 3, 1992, letter, they suggest 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.
2. Lincoln National Life Insurance Company of Indiana.
They also suggest (February 14, 1992) that the family physician bill for antepartum care using the appropriate evaluation and management codes, 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.
3. Office of Medical Assistance Programs (Oregon).
They suggest (March 20, 1992) that the family physician code 59899 for unlisted procedure, maternity care and delivery, as well as 59515-80 if they assist in the Cesarean Section.
If one carefully compares the instructions of the insurance companies with the coding options discussed in this article, then it is easy to see that the family physician would be under-coding the actual work performed.
Of course, coding any unusual codes will undoubtedly require individual review of the submitted claim by the insurance companies. Therefore, it is imperative 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.
Of course, coding any unusual codes will undoubtedly require individual review of the submitted claim by the insurance companies. Therefore, it is imperative 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.
Sample Letter
Many family physicians find it very effective to attach a face letter to the claim, acknowledging that the claim is unusual. A sample of this type of "face letter" follows:
Misc Insurance Company
Anywhere, USA
12345-6789
Patient Name:
Patient Number:
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 prolonged time with the patient. A decision was made to perform a C-section, and a specialist was consulted. I assisted at the C-section 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.
Sincerely,
Doctor's Name
Any claim submitted for unusual circumstances or services should always be manually submitted (hard copy), not electronically submitted.
Misc Insurance Company
Anywhere, USA
12345-6789
Patient Name:
Patient Number:
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 prolonged time with the patient. A decision was made to perform a C-section, and a specialist was consulted. I assisted at the C-section 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.
Sincerely,
Doctor's Name
Any claim submitted for unusual circumstances or services should always be manually submitted (hard copy), not electronically submitted.
