"As with any pregnancy with complications, your first step should be to determine what E/M care the ob global package includes and what may be considered above and beyond and therefore separately billable from the global," says Judy Richardson, MSA, RN, CCS-P, a senior consultant at Hill and Associates Inc., a coding consulting firm in Wilmington, N.C.
Each insurance carrier generally outlines a specific number of visits that it considers part of the global package, which is usually 12 or 13. If the patient has more than the prescribed number of visits and you have documentation backing up the medical necessity for the extra visits, you should charge these outside the global ob fee. Be sure to link any care for the mother and/or fetuses to the appropriate ICD-9 codes, says Dee Mandley, RHIT, CCS, CCS-P, director of HIS and education for CURES, a coding and compliance consulting firm in Twinsburg, Ohio. "For the delivery, the code categories for the mother's record are 651.xx (Multiple gestation) and V27.x (Outcome of delivery), and for the babies' record are 761.5 (Multiple pregnancy) and V31.x-V37.x (Twin and other multiple type of birth)." More Fetuses Mean More Complications Several complications are inherent in multiple gestation pregnancies. For example, ob-gyns automatically consider any such pregnancy as high risk. They involve a number of additional prenatal visits and significantly more monitoring because the physician has to pay attention not only to the mother's health but also to the growth rate and condition of all the fetuses. Specifically with multiparities, the ob-gyn must closely monitor both the mother's and fetuses'blood pressure levels. Typically, this extra care can involve such procedures as fetal non-stress tests (NSTs, 59025, Fetal non-stress test), biophysical profiles (76818, Fetal biophysical profile; with non-stress testing; or 76819, without non-stress testing) and several ultrasounds to monitor the growth of each baby. For example, a patient pregnant with triplets has only 15 prenatal visits (not that far outside the normal routine global period), but she receives four ultrasounds and several injections of Celestone Soluspan to prevent respiratory problems in the fetuses. You should report these items separately from the global period. Report the first ultrasound as 76801 (Ultrasound, pregnant uterus first trimester [<14 weeks 0 days], transabdominal approach; single or first gestation) and two listings of +76802 ( each additional gestation [list separately in addition to code for primary procedure]), or 76805 (Ultrasound, pregnant uterus after first trimester [>14 weeks 0 days], transabdominal approach; single or first [...]