Thank you to the 63 generous coders and billers who answered my questions about billing extra OB visits during the maternity period. If we and our payers are following CPT® rules, these extra visits caring for a pregnant patient are separately billable.
The editorial comments at the start of the Maternity Care and Delivery section tells us what is included in the global payment.
“Antepartum care includes the initial prenatal history and physical examination; subsequent prenatal history and physical examinations; recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation; biweekly visits to 36 weeks gestation; and weekly visits until delivery. Any other visits or services within this time period should be coded separately.”
Notice that it doesn’t say 13 visits, specifically, because patients present at different times in their pregnancy. Don’t just count the visits, count the frequency during the weeks. (monthly, bi-weekly, weekly) CPT® goes on to give examples of complications that should be separately reported, that is, billed in addition to the maternity package.
“Medical complications of pregnancy (eg, cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, preterm labor, premature rupture of membranes, trauma) and medical problems complicating labor and delivery management may require additional resources and may be reported separately.”
OB Coder Survey Results
Before I comment on this, let me give you the results of the survey, and describe your comments.
First, I asked about acute visits in two situations.
What if the OB patient falls or gets a symptom unrelated to the pregnancy? Do you bill it and do you get paid for it? And, if you bill it, do you bill it right away or at the end of the pregnancy?
|Pregnant patient falls and comes to OB office for an unscheduled visit to make sure the baby is okay.|
|Do you bill this visit?||80%||20%|
|If you bill it, do you get paid?||88%||12%|
|Right away||After delivery|
|When do you bill it||85%||15%|
|Pregnant patient gets a terrible cough and comes in to the OB office for an unscheduled visit|
|Do you bill this visit?||87%||13%|
|If you bill it, do you get paid?||86%||14%|
|Right away||After delivery|
|When do you bill it||94%||6%|
A few of you commented on the diagnosis codes that should be used. More on that coming.
What if the patient is high-risk in another way, and needs more frequent visits than those included in the maternity package, defined by CPT®?
|High risk pregnant patient is seen more frequently than defined in the maternity package in CPT®. (Monthly up to 28 weeks, biweekly visits to 36 weeks, weekly visits until delivery.) Your patient comes at more frequent intervals for hyperemesis, or toxemia or opioid addiction or another conditions that increases delivery risk.|
|Do you bill this visit?||77%||23%|
|If you bill it, do you get paid?||72%||285%|
|Right away||After delivery|
|When do you bill it||55%||45%|
So, based on this admittedly small, unscientific survey, many of you are billing and being paid for extra visits. This was surprising to me, based on the what I hear from OB coders. Before we break out the champagne, let me discuss the comments.
- There were numerous comments that said appealing would be needed.
- Some commenters noted that for Medicaid plans that don’t use the global package, they could get paid for E/M services during the global.
- Some commenters said for commercial carriers to whom we send the global bill at the delivery, it is difficult to get paid for extra visits.
- I heard that there are payers with written policies about this issue.
- Someone reminded me that patients will be charged a co-pay for the extra visits, and that their physicians and midwives are reluctant to bill for them.
- One person said, “Overall, we are paid.” We want to work in that state!
- Another person said they have problems with unrelated visits in the post partum period. (sigh)
When I was learning and teaching ICD-10 I joked, Mother’s First! The general guidelines in ICD-10 say,
“Obstetric cases require codes from chapter 15, codes in the range O00-O9A, Pregnancy, Childbirth, and the Puerperium. Chapter 15 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.” 
A few commenters reminded me how important diagnosis coding is to getting these visits paid. In the case of an unrelated condition, such as a fall or cough, use that diagnosis first. One person recommended adding Z33.1, but not pointing to it on the claim form. Notice that the official ICD-10 guidelines tell us that the provider should state the condition being treated isn’t affecting the pregnancy.
In the case of patients who are treated for complications of pregnancy or high-risk pregnancy, it is clear that a code from Chapter 15 (O00—O9A) should be used, and not supervision of normal pregnancy. Pay attention to pre-existing hypertension and to the coding rules related to pre-existing diabetes and gestational diabetes, which I’ve put at the bottom of this post.
My suggestions about diagnosis coding for an acute visit would be to use the reason for the visit and incidental pregnancy, Z33.1. I would not use supervision of normal pregnancy.
For high-risk and complications of pregnancy, use the code from Chapter 15, another code for pre-existing conditions, if any, and the weeks of gestation code.
It would seem that if your Medicaid program wants the visits billed as they happen, it is more likely that you’ll be paid. Check your payers to see if they have policies.
Appeal if denied, however if payer never overturns their own decision, it makes continuing to bill/appeal an exercise in futility. Talk to contracting to see if your contracts with the payer can be amended.
Thank you again to everyone who responded to the survey!
ICD-10 General Guidelines
Pre-existing hypertension in pregnancy
Category O10, Pre-existing hypertension complicating pregnancy, childbirth and the puerperium, includes codes for hypertensive heart and hypertensive chronic kidney disease. When assigning one of the O10 codes that includes hypertensive heart disease or hypertensive chronic kidney disease, it is necessary to add a secondary code from the appropriate hypertension category to specify the type of heart failure or chronic kidney disease.
g. Diabetes mellitus in pregnancy
Diabetes mellitus is a significant complicating factor in pregnancy. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium, first, followed by the appropriate diabetes code(s) (E08- E13) from Chapter 4.
i. Gestational (pregnancy induced) diabetes
Gestational (pregnancy induced) diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. It also puts the woman at greater risk of developing diabetes after the pregnancy. Codes for gestational diabetes are in subcategory O24.4, Gestational diabetes mellitus. No other code from category O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium, should be used with a code from O24.4.
 CPT® Professional Edition, 2018, American Medical Association, p. 381
 ICD-10-CM, General Guidelines