Obstetric care under 2 different carriers

Q A payer wants our office to use the global obstetric code (59400) with the modifier-22 for a patient who switched insurance carriers mid-pregnancy so that another insurance company will be responsible for a portion of the bills. The company also wants us to attach a comment to the claim indicating how many times the patient was seen and the amount of reimbursement from the first insurance carrier. Is this proper?

A No, the insurance company’s recommendations represent inappropriate coding practices. Conventionally, when a patient changes insurance companies mid-pregnancy, the global obstetric code becomes obsolete. Why? Billing for the antepartum visits must be divided between 2 different insurers. Instead, use the code 59425 (4 to 6 antepartum visits) or code 59427 (7+ antepartum visits) to bill each carrier separately and then bill the current payer for the delivery and post-partum care using the code 59410, if it is an uncomplicated vaginal delivery.

Further, the modifier-22 indicates that an unusual service was provided or the course of the pregnancy/delivery/postpartum was complicated. As this is not the case, the insurer’s recommendations do not make sense.

My advice: Get the payer’s requests in writing and inform the insurance plan’s medical director about the recommendations, as well as the implications for incorrect coding.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 A payer wants our office to use the global obstetric code (59400) with the modifier-22 for a patient who switched insurance carriers mid-pregnancy so that another insurance company will be responsible for a portion of the bills. The company also wants us to attach a comment to the claim indicating how many times the patient was seen and the amount of reimbursement from the first insurance carrier. Is this proper?

A No, the insurance company’s recommendations represent inappropriate coding practices. Conventionally, when a patient changes insurance companies mid-pregnancy, the global obstetric code becomes obsolete. Why? Billing for the antepartum visits must be divided between 2 different insurers. Instead, use the code 59425 (4 to 6 antepartum visits) or code 59427 (7+ antepartum visits) to bill each carrier separately and then bill the current payer for the delivery and post-partum care using the code 59410, if it is an uncomplicated vaginal delivery.

Further, the modifier-22 indicates that an unusual service was provided or the course of the pregnancy/delivery/postpartum was complicated. As this is not the case, the insurer’s recommendations do not make sense.

My advice: Get the payer’s requests in writing and inform the insurance plan’s medical director about the recommendations, as well as the implications for incorrect coding.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 A payer wants our office to use the global obstetric code (59400) with the modifier-22 for a patient who switched insurance carriers mid-pregnancy so that another insurance company will be responsible for a portion of the bills. The company also wants us to attach a comment to the claim indicating how many times the patient was seen and the amount of reimbursement from the first insurance carrier. Is this proper?

A No, the insurance company’s recommendations represent inappropriate coding practices. Conventionally, when a patient changes insurance companies mid-pregnancy, the global obstetric code becomes obsolete. Why? Billing for the antepartum visits must be divided between 2 different insurers. Instead, use the code 59425 (4 to 6 antepartum visits) or code 59427 (7+ antepartum visits) to bill each carrier separately and then bill the current payer for the delivery and post-partum care using the code 59410, if it is an uncomplicated vaginal delivery.

Further, the modifier-22 indicates that an unusual service was provided or the course of the pregnancy/delivery/postpartum was complicated. As this is not the case, the insurer’s recommendations do not make sense.

My advice: Get the payer’s requests in writing and inform the insurance plan’s medical director about the recommendations, as well as the implications for incorrect coding.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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.