Know when and how to report fee-for-service obstetric visits.

Many obstetric offices charge for obstetric (OB) visits using a global care code. In some cases, however, you may need to report OB visits individually as fee-for-service visits. Let’s review the steps to ensure your providers are hitting all documentation requirements for these services.

Step 1: Recognize when Fee-for-Service Is Appropriate

As part of the “typical” global obstetrical package, the provider will see the patient:

Once a month until the patient reaches 28 weeks; then once every two weeks until the patient reaches 36 weeks; and then weekly until the patient delivers.

Usually, these services are billed using a single global CPT® code at the end of the pregnancy. The appropriate code depends on the patient’s delivery type. For example:

59400     Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

59510     Routine obstetric care including antepartum care, cesarean delivery, and postpartum care

59610     Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

But what happens if the patient moves out of state and needs to resume prenatal care via a different provider? Or the patient’s employer changes insurance carriers during the pregnancy? These instances require fee-for-service billing.

Step 2: Be Sure Documentation Supports the Services

Documentation requirements for fee-for-service routine OB charges are no different than the requirements for any other fee-for-service charge. Evaluation and management (E/M) guidelines indicate an addressed abnormality or complaint establishes a problem-oriented E/M service reported with a CPT® code from range 99201-99215.

A chief compliant (CC) is required for all levels. The degree of information gathered for the remaining elements related to a patient’s history depends on the clinician’s judgement and the nature of the presenting problem. The CC for this type of patient can be as simple as routine obstetrics (ROB) or as complex as:

A 25-year-old Gravida I Para 0-0-0-0 female complains of nausea in the morning for the past 2 weeks. She has been able to tolerate the nausea because it usually subsides by 10 a.m. She is very active with a full-time legal aid position, but has noted more fatigue at the end of the day. She has not had any vaginal bleeding. She has not felt fetal movement as of this time.

The history of present illness (HPI) is a sequential description of the development of the patient’s present illness from the first sign/symptom or from the previous encounter to the present. This is also a required element when reporting fee-for-service OB visits. The HPI elements are:

• Location (e.g., labia)
• Quality (e.g., aching, burning, radiating pain)
• Severity (e.g., 10 on a scale of 1 to 10)
• Duration (e.g., started 3 days ago)
• Timing (e.g., constant or comes and goes)
• Context (e.g., coitus)
• Modifying factors (e.g., better when heat is applied)
• Associated signs and symptoms (e.g., numbness in toes)

There are two different types of HPI: brief and extended. The HPI for this type of patient can be as simple as “doing well,” or it can go on to list the problems the patient may have had in the interim.

The review of systems (ROS) is a list of body systems attained by asking the patient different questions. This is another required E/M element for any problem-focused visit. There are three different types of ROS: problem pertinent, extended, and complete. For an OB patient, the provider may document something as simple as “GYN ROS negative;” or they may document a more extended or complete ROS, depending on the severity of what the patient’s complaint. In all cases, the extent of the ROS should be supported by medical necessity.

A physical exam (required) may involve several organ systems or a single organ system. The type and degree of the completed exam is based on the clinician’s judgement, the patient’s history, and the nature of the presenting problem. This information can be pulled from the patient’s prenatal summary, kept and reviewed at each patient visit, which includes height, weight, fundal height, fetal movement, fetal heart rate, and urinalysis results obtained at the beginning of the visit.

Medical decision-making (MDM) refers to the complexity of establishing a diagnosis and selecting management options. This is determined by the number of possible diagnoses and management options, as well as the amount and complexity of medical records, diagnostic tests, and other information that must be acquired, reviewed, and evaluated. This is where the provider documents prenatal labs the patient needs completed, as well as radiology testing, medication, etc. The provider also reviews the testing results with the patient and makes recommendations and directions that the patient needs to follow until her next visit.

Step 3: Don’t Overdo It

Although including all the required elements (detailed above) may seem like a lot of information, these can be simple notes that don’t require a lot of extra information.

Here’s a great example of a problem-oriented OB visit:

S- 25-year-old Gravida I Para 0-0-0-0 female complains of nausea in the morning for the past 2 weeks. She has been able to tolerate the nausea because it usually subsides by 10 a.m. She is very active with a full-time legal aid position, but has noted more fatigue at the end of the day. She has not had any vaginal bleeding. She has not felt fetal movement as of this time.

O- B.P. 120/80, P 72, Weight 130

Uterine Size about 2 cm below the umbilicus FHT 120

Urinalysis – negative

Here’s an example of a patient at 12-weeks gestation with nausea:

P- 1. Continue taking prenatal vitamins.

2. Supportive care for nausea – to notify me if increased problems.
3. Offer childbirth classes in the future.
4. Appointment in 4 weeks with UA.

Finally, here’s a great example of a routine OB visit:

CC: ROB – doing well

GYN ROS – neg

Reviewed prenatal lab results, discussed nutrition, fetal screening options. RTC in 4 weeks.

By having your provider add a bit more documentation in the front end, you can ensure they are being reimbursed appropriately for their time spent on the back end.

Morgan Jones CPC, COBGC, CPRC, is senior clinic coder for a large healthcare system in the Midwest and a member of the St. Louis West, Mo., local chapter.