Can nurse-midwife bill for prolonged physician services?

Q How can a certified nurse-midwife (CNM) recoup time spent with a laboring patient when a physician performs the delivery? A seminar speaker once indicated CNMs could bill prolonged physician services. For instance, what if the CNM admits the patient for delivery on day 1 and spends 1 hour with her and then on day 2 spends 6 hours with her before the decision is made to proceed to cesarean delivery?

A You can only use the add-on prolonged services codes 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and 99357 (each additional 30 minutes) if you are also billing for inpatient care and the record clearly documents the need for the prolonged care. Face-to-face time must be documented to use these codes, not unit/floor time. This is one way that the CNM or family practice physician can bill for labor management when they do not do the delivery.

To report these codes, the typical time included in the base inpatient service you are billing for must be exceeded by 30 minutes. For instance, code 99222 (initial hospital care, requiring a comprehensive history; a comprehensive exam and medical decision making of moderate complexity) has a typical time of 50 minutes. Since in your example the CNM spent only 1 hour face-to-face with the patient on the admission day, the criterion for reporting prolonged services has not been met and code 99356 cannot be billed in addition to 99222.

On the second day, however, prolonged services can be billed. Let’s use the example of 6 hours and assume the subsequent hospital care code billed on that day was 99233 (subsequent hospital care, requiring high complexity of medical decision making and a detailed history or exam). The typical time for this code is 35 minutes.

To determine billable prolonged service time, subtract typical time from the total face-to-face time (in this case 360 minutes), then subtract 30 because the first 30 minutes of prolonged time is not reported (360–35–30=295). Thus on day 2 you could bill 99233, plus 99356×1 for the first hour of prolonged service, and 99357×8 for the 8 remaining half-hour increments of prolonged time.

Two caveats, however. First, CPT nomenclature for the prolonged services codes indicate “physician service,” which means that some payers may not reimburse for prolonged services unless provided by a physician.

Second, if the CNM is unable to bill for the global service, but instead must itemize the services provided by billing separately for antepartum care (eg, 59426, antepartum care only; 7 or more visits) and postpartum care (59430, postpartum care only [separate procedure]), some payers may include the time spent with the laboring patient as part of the antepartum services. Check with the individual payer to see if they have a written policy regarding this situation.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q How can a certified nurse-midwife (CNM) recoup time spent with a laboring patient when a physician performs the delivery? A seminar speaker once indicated CNMs could bill prolonged physician services. For instance, what if the CNM admits the patient for delivery on day 1 and spends 1 hour with her and then on day 2 spends 6 hours with her before the decision is made to proceed to cesarean delivery?

A You can only use the add-on prolonged services codes 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and 99357 (each additional 30 minutes) if you are also billing for inpatient care and the record clearly documents the need for the prolonged care. Face-to-face time must be documented to use these codes, not unit/floor time. This is one way that the CNM or family practice physician can bill for labor management when they do not do the delivery.

To report these codes, the typical time included in the base inpatient service you are billing for must be exceeded by 30 minutes. For instance, code 99222 (initial hospital care, requiring a comprehensive history; a comprehensive exam and medical decision making of moderate complexity) has a typical time of 50 minutes. Since in your example the CNM spent only 1 hour face-to-face with the patient on the admission day, the criterion for reporting prolonged services has not been met and code 99356 cannot be billed in addition to 99222.

On the second day, however, prolonged services can be billed. Let’s use the example of 6 hours and assume the subsequent hospital care code billed on that day was 99233 (subsequent hospital care, requiring high complexity of medical decision making and a detailed history or exam). The typical time for this code is 35 minutes.

To determine billable prolonged service time, subtract typical time from the total face-to-face time (in this case 360 minutes), then subtract 30 because the first 30 minutes of prolonged time is not reported (360–35–30=295). Thus on day 2 you could bill 99233, plus 99356×1 for the first hour of prolonged service, and 99357×8 for the 8 remaining half-hour increments of prolonged time.

Two caveats, however. First, CPT nomenclature for the prolonged services codes indicate “physician service,” which means that some payers may not reimburse for prolonged services unless provided by a physician.

Second, if the CNM is unable to bill for the global service, but instead must itemize the services provided by billing separately for antepartum care (eg, 59426, antepartum care only; 7 or more visits) and postpartum care (59430, postpartum care only [separate procedure]), some payers may include the time spent with the laboring patient as part of the antepartum services. Check with the individual payer to see if they have a written policy regarding this situation.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q How can a certified nurse-midwife (CNM) recoup time spent with a laboring patient when a physician performs the delivery? A seminar speaker once indicated CNMs could bill prolonged physician services. For instance, what if the CNM admits the patient for delivery on day 1 and spends 1 hour with her and then on day 2 spends 6 hours with her before the decision is made to proceed to cesarean delivery?

A You can only use the add-on prolonged services codes 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and 99357 (each additional 30 minutes) if you are also billing for inpatient care and the record clearly documents the need for the prolonged care. Face-to-face time must be documented to use these codes, not unit/floor time. This is one way that the CNM or family practice physician can bill for labor management when they do not do the delivery.

To report these codes, the typical time included in the base inpatient service you are billing for must be exceeded by 30 minutes. For instance, code 99222 (initial hospital care, requiring a comprehensive history; a comprehensive exam and medical decision making of moderate complexity) has a typical time of 50 minutes. Since in your example the CNM spent only 1 hour face-to-face with the patient on the admission day, the criterion for reporting prolonged services has not been met and code 99356 cannot be billed in addition to 99222.

On the second day, however, prolonged services can be billed. Let’s use the example of 6 hours and assume the subsequent hospital care code billed on that day was 99233 (subsequent hospital care, requiring high complexity of medical decision making and a detailed history or exam). The typical time for this code is 35 minutes.

To determine billable prolonged service time, subtract typical time from the total face-to-face time (in this case 360 minutes), then subtract 30 because the first 30 minutes of prolonged time is not reported (360–35–30=295). Thus on day 2 you could bill 99233, plus 99356×1 for the first hour of prolonged service, and 99357×8 for the 8 remaining half-hour increments of prolonged time.

Two caveats, however. First, CPT nomenclature for the prolonged services codes indicate “physician service,” which means that some payers may not reimburse for prolonged services unless provided by a physician.

Second, if the CNM is unable to bill for the global service, but instead must itemize the services provided by billing separately for antepartum care (eg, 59426, antepartum care only; 7 or more visits) and postpartum care (59430, postpartum care only [separate procedure]), some payers may include the time spent with the laboring patient as part of the antepartum services. Check with the individual payer to see if they have a written policy regarding this situation.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.