Obstetric and Gynecologic CPT
Coding
AAPC Chapter Meeting
Presented by: Deb Kuehn, CPC, CMRS
July 18, 2013
Overview
• Global OB Coding and guidelines for use
• Review individual and package coding for OB services
not part of a Global
• Medicare GYN coverage – criteria and coding
guidelines
• Other GYN services and procedures
• Diagnosis coding for OB and GYN services
• Medical Necessity
2
Global codes for OB Care
• CPT codes for global OB care are:
o
o
o
o
59400 Total OB care with routine vaginal delivery
59510 Total OB care with routine cesarean delivery
59610 Total OB care with routine VBAC delivery
59618 Total OB care with routine repeat cesarean
delivery after attempted VBAC delivery
3
Component Codes for OB care
o CPT codes for providers who do not furnish the
entire global package are:
o 59409 Vaginal delivery only (with or without episiotomy
and/or forceps);
o 59410 Vaginal delivery only (with or without episiotomy
and/or forceps); including postpartum care
o 59425 Antepartum care only; 4-6 visits
o Less than 4 antepartum visits should be coded with the
appropriate E/M level
o 59426 Antepartum care only; 7 or more visits
o 59430 Postpartum care only (separate procedure)
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Component codes for OB care
• 59414 Cesarean delivery only
• 59415 Cesarean delivery only; including postpartum
care
• 59525 Subtotal or total hysterectomy after cesarean
delivery (List separately in addition to code for
primary procedure)
5
59400 and 59510 Global Routine
Obstetric Care
• These CPT codes are inclusive of:
– Antepartum care,
– 59400 - Vaginal delivery (with or without
episiotomy, and/or forceps) 59510 Cesarean
delivery (with or without episiotomy, and/or
forceps) and
– Postpartum care
• The rules that pertain to the use of this code include
a)
The provider billing for OB care must have rendered at least 3
months of consecutive antepartum care to the recipient.
b) The date the provider first saw the recipient for antepartum care
must appear in block 15 of the CMS-1500 form.
c) The date of service on the claim for the OB care must be the date of
delivery.
d) These codes cannot be billed in addition to other OB global codes.
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Antepartum Care
• Several of the global delivery CPT codes include the
term “Routine Antepartum Care”. This is defined as:
– Monthly visits up to 28 weeks gestation
– Biweekly visits to 36 weeks gestation, and
– Weekly visits until delivery
 For high risk pregnancies requiring more than the
“routine” care additional E/M visits may be coded
separately using CPT codes 99212-99215 as appropriate.
NOTE: Recommend practices mark high risk patient charts
for audit for additional visits when billing for the global
care.
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Routine Vaginal Delivery
 INCLUDES: Care provided for an uncomplicated pregnancy
including delivery as well as antepartum and postpartum care:
Admission history
Admission to hospital
Artificial rupture of membranes
Management of uncomplicated labor
Physical exam
Vaginal delivery with or without episiotomy or forceps
EXCLUDED: Are medical or surgical complications fo the
pregnancy including hernia repair, excision or destruction of
bartholin or ovarian cysts and treatment of other medical
problems such as cardiac or endocrine disorders.
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Postpartum Care
• The postpartum period includes 60 days of follow-up care after the
date of delivery.
• Postpartum care is not reimbursed separately when an OB global
code is billed.
• Medicaid reimburses providers for family planning procedures,
including sterilization, when provided during this period.
• The spans of dates during and after the pregnancy are very
different than the spans of dates typically associated with minor
and major surgical pre- and post-operative periods.
• When a provider renders services on the date of delivery or during
the postpartum period that are unrelated to the actual pregnancy
or delivery, the provider can bill an Evaluation and Management
(E/M) procedure code appended with modifier 24 or 25, as
applicable.
• NOTE – Be sure to use the diagnosis code that supports the
medical necessity of the additional service to assist in payment.
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59409 and 59410 – Delivery and
Delivery/Postpartum care only
• 59409 – this CPT denotes that the physician delivering
the infant is only providing the delivery portion of the
care.
• Most often occurs if another physician outside of the
group has to deliver.
• Does not include any antepartum or postpartum care.
• If the delivering physician (who did not provide any care
prior to the birth) also providers postpartum care use
code 59410 for both the delivery and postpartum care.
• If the delivering physician did see the patient for
antepartum care, but it was 3 visits or less, then those
should also be coded with the appropriate E/M code.
10
59414 – Delivery of Placenta (Separate
Procedure)
• CPT Code 59414 – Delivery of Placenta should only
be reported when the procedure is done separately
from the routine delivery.
• If performed immediately following the delivery it is
included in the global charge.
• Example of where it would be separately billable
include:
– Placenta is retained and requires another provider to
deliver at an interval following the delivery
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59425 Antepartum Care only (4-6
visits) and 59426 (7 or more visits)
• The provider billing for OB care must have rendered at
least 3 months of consecutive antepartum care to the
recipient.
• The date the provider first saw the recipient for
antepartum care must appear in block 15 of the CMS1500 form.
• The date of service on the claim must be the date of
delivery.
• This code cannot be billed in addition to other OB global
codes.
• A provider can bill this code once during the pregnancy
with one unit.
• Delivery and postpartum care are to be billed in addition
to this code
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• 59618 Routine obstetric care including antepartum care,
cesarean delivery, and postpartum care, following
attempted vaginal delivery after previous cesarean
delivery
• 59620 Cesarean delivery only, following attempted
vaginal delivery after previous cesarean delivery
• 59621 Cesarean delivery only, following attempted
vaginal delivery after previous cesarean delivery;
including postpartum care
• NOTE – When coding for cesarean delivery make sure
you know how previous pregnancies were delivered.
These codes carry a higher reimbursement that routine
cesarean delivery itself.
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Obstetric Diagnosis Coding
• Coders must make sure they understand which
diagnosis and procedure codes are appropriate for
obstetric/maternity services.
• ICD-9-CM codes 630–679 are specific to the mother
and what is happening to her.
• Codes 760–779 are for the fetus/neonate/baby.
NOTE - It is important to know whether you are coding
for the mother, the baby, or both, and assign the
appropriate set of diagnosis codes.
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Diagnosis coding for Obstetrics
• ICD-9 codes for routine global OB care are:
o 650 Routine vaginal delivery, and the appropriate
V27.x code for the outcome of the delivery.
o 654.21 Prior cesarean section delivery used for
repeat c-section and for VBAC delivery, and the
appropriate V27.x code for the outcome of the
delivery.
o Primary cesarean section delivery ICD-9 codes
should be the diagnosis code for the condition
requiring c-section delivery (eg, obstructed labor
660.xx, or abnormality forces of labor 661.xx), and
the appropriate V27.x code for the outcome of the
delivery.
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Routine OB Diagnosis Codes
• ICD-9 codes for routine global OB care include:
• 650 Routine vaginal delivery, and the appropriate V27.x
code for the outcome of the delivery.
• 654.21 Prior cesarean section delivery used for repeat csection and for VBAC delivery, and the appropriate V27.x
code for the outcome of the delivery.
• Primary cesarean section delivery ICD-9 codes should be
the diagnosis code for the condition requiring c-section
delivery (e.g., obstructed labor 660.xx, or abnormality
forces of labor 661.xx)., and the appropriate V27.x code for
the outcome of the delivery.
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Fetal Biophysical Profile with NST
76818 - Fetal
• Are covered for additional fetuses.
biophysical profile; • The first fetus should be billed on one
with nonstress
detail line, no modifier with 1 unit of
testing
service.
78819 - Fetal
biophysical profile;
without nonstress
testing
Additional fetus(es) should be billed on the
next detail line with modifier 59,and the
number of units should equal the number
of additional fetuses
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Ultrasounds
• Ultrasounds are covered when medically necessary.
• Medicaid covers three ultrasounds within 280 days
for the same or different provider for normal
pregnancy.
• If additional ultrasounds are required, the diagnosis
code must indicate high-risk conditions warranting
additional ultrasounds.
• NOTE – If taking a transfer OB patient be sure to
obtain copies of the patient’s records to confirm
treatment which may have time or unit limitations.
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Ultrasounds for Multiple Fetuses
• Claims denied for additional ultrasounds may be
resubmitted as an adjustment with documentation
to support the medical necessity of a repeat
ultrasound on the same date of service.
• In cases of fetal demise, the ultrasound procedure
that confirms the loss of one or more fetuses may be
billed with units to include the total number of
additional fetuses, dead and living.
• Subsequent billings should be billed with the units
based on the number of “each additional” living fetus
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Medicare Coverage for GYN
• Comprehensive preventive exams i.e. Well Woman
are never covered
• However, Medicare does cover certain components
of GYN care for it’s female beneficiaries. These
include:





Pelvic/clinical breast exam (G0101)
Screening Pap test (Q0091)
Screening hemoccult (82270 or 82272)
Screening mammography (77057)
Bone mass measurement (77080-77082)
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Medicare Coverage for GYN (cont.)
 Initial Preventive Physical Examination (IPPE within 6
months of Medicare enrollment)**
 Diabetes screening and self management (G0108)
 Cardiovascular screening
 Depression and alcohol abuse screening
 Smoking Cessation counseling (G0436 up to 10
minutes, G0437 greater than 10 minutes)
 Annual wellness examination with personalized
prevention plan of service (G0438 initial visit and
G0439 subsequent visit)
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Initial Annual Wellness Visit (AWV)
• The initial annual wellness visit (AWV) includes :
 taking the patient's history;
 compiling a list of the patient's current providers;
 taking the patient's vital signs, including height and weight;
 reviewing the patient's risk factor for depression;
identifying any cognitive impairment;
 reviewing the patient's functional ability and level of safety
(based on observation or screening questions);
 setting up a written patient screening schedule;
 compiling a list of risk factors, and furnishing personalized
health services and referrals, as necessary.
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Subsequent Annual Wellness Visit
(AWV)
The subsequent annual wellness visits (AWV) includes:
 updating the patient's medical and family history,
updating the current provider list,
obtaining the patient's vital signs and weight,
identifying cognitive impairment,
updating the screening schedule,
updating the risk factors list, and
providing personalized health advice to the patient.
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Guidelines for Collection of Pap
Smears
• Pap smear CPT codes should not be used to bill collection
of a specimen.
• Collection of the smear is included in the reimbursement
for office visits and no separate fee is allowed.
• Providers who do not perform the lab test should not bill
the pap smears.
• Only the provider who actually performs the lab test
should bill the pap smear codes, except as noted below
for physician interpretation.
• NOTE – CPT code 99000 is not appropriate to bill for
sending the pap sepecimen to the lab. This code should
only be billed for specimens sent to a lab where the
physician incurs an additional cost for transportation.
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Medicare IPPE**
• G0402 Initial preventive physical examination; face-toface visit, services limited to new beneficiary during the
first 12 months of Medicare enrollment
• G0403 Electrocardiogram, routine ECG with 12 leads;
performed as a screening for the initial preventive
physical examination with interpretation and report
• G0404 Electrocardiogram, routine ECG with 12 leads;
tracing only, without interpretation and report,
performed as a screening for the initial preventive
physical examination
• G0405 Electrocardiogram, routine ECG with 12 leads;
interpretation and report only, performed as a screening
for the initial preventive physical examination
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Screening Pelvic and Clinical Breast
Exam (CPT Code G0101)
• Covered once every 2 years for all women
• Annually for high risk beneficiaries. This includes:
–
–
–
–
–
–
–
–
Childbearing age and any of the following apply:
Cervical or vaginal cancer is/was present
Abnormalities found in preceding 3 years
Onset of sexual activity under age 16
Five or more sexual partners in a lifetime
History of STI (including HIV)
Fewer than 3 negative Pap smears within previous 7 years
Absence of any Pap smear within previous 7 years
• Both deductible and co-pays are waived under the
Affordable Care Act (ACA)
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Screening Pelvic and Clinical Breast
Exam
• In order for the screening Pelvic and Breast exam to be
billable 7 of the following 11 exam elements must be
documented:
 Inspection/palpation of breasts
 Digital rectal
 External genitalia
 Urethral meatus
 Urethra
 Bladder
 Vagina
 Cervix
 Uterus
 Adnexa/parametria
 Anus and perineum
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Screening Pelvic and Clinical Breast
Exam
• HCPCS codes for reporting are:
• Screening pelvic/clinical breast exam:
o G0101
• Collection of screening pap smear:
o Q0091
• Q0091, G0101, and/or problem-oriented E/M
• ICD-9 CM codes:
o V15.89 High risk
o V72.31 Routine gynecological exam (only if comprehensive
preventive service performed)
o V76.2 Cervix V76.47 Vagina V76.49 Other sites
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Additional E/M services
• If the provider encounters a medical condition requiring
treatment this may be billed using the appropriate level
of E/M service.
• Modifier 25 will be required to avoid payment bundling
edits.
• There should be distinct documentation as to the
medical condition and the non-GYN diagnosis code
should be documented and linked to the E/M
• NOTE – Always be careful to link preventive codes with
preventive diagnosis and E/M with clinical diagnosis
codes, do not mix and match.
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Mammography and Screening
Guidelines
• Screening mammography is a radiological procedure
furnished to a woman without signs or symptoms of breast
disease, for the purpose of early detection of breast cancer.
• Mammograms are covered only when performed by an FDA
certified screening center/suppliers. Interpretations are to be
performed only by physicians who are included under the
certification number of a certified screening center/supplier.
• Medicaid only covers a mammography screening for the age
range below:
– 35 through 39 Baseline (only one allowed in this age group)
– 40 and over Annual (11 months must have elapsed since the month of
last screening)
• NOTE: Months between mammographies are counted
beginning with the month after the date of the examination
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Hysterectomy Coding
• Hysterectomy codes are reported using the range 58150
– 58294.
• Use 59525 for a hysterectomy following a cesarean
section.
• The hysterectomy diagnosis must support the medical
necessity for the hysterectomy.
• Hysterectomy claims for recipients with a diagnosis of
cervical dysplasia, pelvic pain, or pelvic inflammatory
disease should be submitted with the following medical
records:
– history and physical, operative notes, pathology report,
discharge summary and reports for treatments performed
prior to the hysterectomy (such as laparoscopic procedures,
D & Cs, conizations, or cervical biopsies).
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Other Services
• Sterilization procedures are coding using 58600 –
58671.
• This procedure should be billed in addition to any
other services performed, including OB care.
• Diagnosis code for sterilization is V25.2
• Medicaid will not cover sterilization reversals.
• Pessary fitting and insertion CPT code 57160
• Pessary supply non rubber HCPCS code A4562 and
rubber A4561
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Federal Sterilization Guidelines
• The sterilization consent form is a federally mandated document.
• Medicaid covers an individual to be sterilized only if the following
guidelines listed in 42 CFR 441.253 are met:
1. The individual is at least 21 years old at the time the sterilization
consent is obtained.
2. The individual is not a mentally incompetent individual.
3. At least 30 days, but not more than 180 days have passed
between the date of informed consent and the date of the
sterilization
4. Counseled in alternative methods of family planning and birth
control.
5. Advised that the sterilization procedure is considered to be
irreversible.
6. Provided a thorough explanation of the specific sterilization
procedure to be performed
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Birth Control Coding
• Medicaid covers medically approved birth control methods
such as Nuva Ring, Ortho Evra, emergency contraceptive
counseling, contraceptive management procedures, and
pharmaceuticals to prevent conception.
• Birth control pills may be dispensed through a pharmacy. A
recipient may receive up to a 3-month supply.
• Diaphragm as a birth control method. A physician can fit the
recipient and bill using CPT 57170 for diaphragm fitting.
• The codes for IUD insertion correspond to the specific
intrauterine device (IUD).
• J7300 Para gard
• J7302 Mirena
• When billing for IUD insertion, CPT code 58300 is used.
• The CPT code for removal of IUD is 58301, which includes an
office visit.
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Birth Control Coding
• Depo-Provera contraceptive injection, J1055, is a
covered service. Providers are advised to use an
appropriate diagnosis code for contraceptive
management.
• The appropriate office visit code may be billed
separately, unless the service is only the
administration of the injectable drug in which case a
provider can bill the injectable administration fee in
addition to the Depo-Provera injection code.
• Medicaid covers the removal of Norplant. The global
period for CPT 11976 is one (1) pre-care day and
ninety (90) postoperative days.
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Questions
• Contact Information
– Deb.Kuehn@USHWorks.com
– 615-504-6913
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Thank you!
Any Questions?