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Ob-Gyn Coding Alert

Reader Questions:
Carrier Policies Determine Pay for Prenatal Visits

Question: We saw a patient for 15 prenatal visits. Two of the visits were for complications with pregnancy. Should we bill these two visits with an E/M code and not 59426?

Illinois Subscriber  
Answer: Code 59426 (Antepartum care only; 7 or more visits) implies normal antepartum care. Consequently, you should report the two complication-centered visits using E/M codes (for example, 99211-99215 for an established outpatient). But you are going to be faced with different payer policies when billing for complications of pregnancy. The following examples delineate the various scenarios you may face and how to code in each case:
 
 Payer 1 follows CPT rules. The ob package includes all normal prenatal care. You report any visits for complications of pregnancy or unrelated visits on the day they occur. In the case above, you could end up with 13 normal antepartum visits as part of the ob package (linked to V22.x, Normal pregnancy) and two E/M visits for the complications (linked to the diagnosis code for the complication).
 
 Payer 2 includes all prenatal care, complicated or uncomplicated, in the global period. In this case, you cannot report extra visits for complications. And although your records may indicate that on two of the visits there was a complication, you only get to report the current diagnosis profile at the time of delivery when you report the global code.
 
 Payer 3 allows you to bill for complications of pregnancy, but not until you have provided 13 antepartum visits. If you provide more than 13 prenatal visits, you can report them as E/M services linked to the diagnosis code for the complication(s).

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