In an OB/GYN hospitalist practice, there are many challenging medical and billing situations routinely encountered. Coding and billing for these scenarios, documenting properly, submitting to third-party payers, and getting appropriately reimbursed are integral to keeping an OB/GYN hospitalist practice solvent and thriving.

At this time in the OB/GYN hospitalist specialty, there are many practice and billing models to choose among, and determining which one is right for your practice can be confusing. In addition, OB/GYN hospitalists encounter patients who do not have access to or have not chosen to see a traditional obstetrician to oversee their care. Many patients also rely on the OB/GYN hospitalist to respond to emergencies and care for them around the clock. In many instances, traditional OB/GYN providers consult with hospitalists to augment and provide specialty, hospital-based services for high-risk patients. The OB/GYN hospitalist program concept is new in the United States. Coding and billing for this subspecialty pose a bigger challenge for providers, hospitals, and coding/billing staff. OB/GYN hospitalists are bearing the burden of maintaining above-standard specialty patient care, while remaining fiscally solvent.

OB/GYN hospitalist programs have a positive impact on high-risk obstetric healthcare because they enable patients to have emergent attention when their own physician is unavailable. Of course, hospitalists provide many other functions, such as supporting local obstetricians as backups for deliveries and emergency cesarean sections (C-sections), providing ancillary testing services for walk-in or emergent trauma situations, and stepping in as assistant surgeons for many operative procedures.

The fiscal mainstay for the OB/GYN hospitalist practice is evaluation and management (E&M) services. These include all areas of inpatient hospital, outpatient hospital, Emergency Department, critical care, complex care management, and office quick/urgent care coding. In addition to the evaluation and management codes, procedure-based Current Procedural Terminology (CPT) codes provide an enormous source of revenue. These codes include surgery; interventional, diagnostic, and therapeutic medicine; and radiology/ultrasound services. Not only does an OB/GYN hospitalist team provide these services but it is also instrumental in leading to “downstream” revenue that ultimately benefits healthcare facilities, such as laboratory, radiology, neonatal intensive care unit (NICU), pharmacy, nutritional, and social work services.

Each OB/GYN hospitalist program functions under different licenses within the hospital setting. Some practices are embedded with the emergency room (ER), some are an integral part of the Labor and Delivery (L&D) floor, and others operate as an emergent outpatient area of the hospital, similar to a quick-care or urgent-care walk-in clinic. The most common structure includes the OB/GYN hospitalist stand-alone practice that functions as a separately identifiable group and bills as a physician-based practice team. They usually code and bill with their own management software, coding/billing team, or both.

Coding and billing in an OB/GYN hospitalist practice is a specialty concept within itself. The OB/GYN hospitalist practice has to provide superior care not only for the pregnant patient but also for the fetus. Many times during routine coding and billing audits, the high-risk factor is overlooked or undervalued during the scoring when determining the evaluation, plan of care, clinical documentation, risk factors, proposed procedures, and ancillary service options.

The details of traditional CPT evaluation/management and procedure codes are utilized in addition to the current International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis code set. Clinical documentation by the OB/GYN hospitalist is integral to successful billing. The coder has to combine all the pieces of the evaluation and management code, the procedures performed, the diagnosis, and any relevant ancillary circumstances. Common OB/GYN hospitalist procedures are listed in Table 6-1.

Education in coding, billing, and clinical documentation for the OB/GYN hospitalist practice are important areas to review and consider when implementing a new practice or working to revitalize a practice struggling with financial problems. Procedure and diagnosis coding is the foundation for payment processes from insurance carriers for hospitals, facilities, and physician-based charges.

As a provider, you may be asked to utilize an electronic coding and documentation system. The patients’ diagnosis, which is coded in ICD-10-CM, will always be the driver for the medical necessity of a reimbursement claim. The clinical documentation provided for any procedure or work performed will be the foundation for the CPT procedure code, ICD-10-Procedural Classification System (ICD-10-PCS) code, or both. CPT and ICD-10-PCS are both procedure-based coding systems. Normally, physician-based charges are coded with CPT and hospital-based facility charges are coded with ICD-10-PCS. When coding, the listed items in Table 6-2 go hand in hand with the clinical documentation.

STANDARD CODING PROCESS

The standard coding process for IC-10-CM is actually a very simplistic system. However, there are numerous guidelines in place for accurate coding and compliance for reimbursement services. The World Health Organization (WHO) is charged with doing the oversight and upgrades to adding, deleting, and updating all diagnoses included within the US version of ICD-10-CM. However, ICD-10 has been implemented worldwide at this point in time. On October 1, 2015, the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) system was replaced in the United States with the upgrade to the ICD-10-CM version. This upgrade allowed for expansion of diagnosis codes and better clinical documentation. This information is compiled and used as a data-driven code set for analysis by payers and organizations using this data for research or disease processes.

QUICK INTRODUCTION TO USING ICD-10-CM

The ICD-10-CM book is comprised of two separate sections: the alphabetic index and the numeric/tabular section. The procedure and codes for ICD-10 can be found in the electronic resource for documentation within your facility, as a Portable Document Format (PDF) file accessed through the internet under many different coding websites, or as a hard copy from an ICD-10 book (Fig. 6-1).

TABULAR LIST

The numerical listing of codes in ICD-10 is divided into 21 chapters. The code designation for Chapters 1–19 (A–T) are separated based upon the anatomy and organ structures. The codes that begin with V, W, X, and Y are designated to classify factors influencing health status and contact with health services, and the codes that begin with Z are designed to classify external causes of injury and poisoning.

With the code structure in ICD-10, it is noted that a code of at least three characters can be used, provided that there are no further specificity expansions to the diagnosis. However, if a more specific code is available, the most specific code is to be used. With regard to using the third characters (main code/category), it may be used as the primary code if no further specificity is required. The fourth character then appears after a decimal point. The fourth character defines the site, etiology, and manifestation. The fifth and sixth characters define even further specificity of the clinical picture. The seventh character (if required) will identify the status of care.

ICD-10 COMMON CATEGORIES USED IN OB/GYN HOSPITALIST DIAGNOSING

The codes listed next are strictly the categories of ICD-10 diagnosis coding. However, specificity is required, and all ICD-10 diagnosis codes have a minimum of three- to seven-character alphanumeric codes. The full code set can be found at the following website: https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

Again, ICD-10-CM has very complex coding rules and guidelines that need to be followed closely. For specific ICD-10 coding guidelines, please refer to the most current ICD-10-CM coding references. The codes listed in Figure 6-2 are only the starting point to diagnosing the patient’s condition and presenting medical issues accurately.

QUICK Q&A: CHECK YOURSELF ICD-10 DIAGNOSIS

1. 
   

   Patient is a 38-year-old G3P1 at 26 and 2/7 weeks’ gestation seen today at the L&D outpatient department for gestational hypertension. No other problems are noted. What are the correct diagnosis codes?

   
   
   
   
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     Answer: O13.2 Gestational hypertension w/o significant proteinuria, 2nd trimester

     
     
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     O09.522 Supervision of elderly multigravida, second trimester

     
     
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     Z3A.26 26 weeks gestation of pregnancy

   
   
   
   
2. 
   

   Patient is a 22-year-old G1P0 at 16 weeks’ gestation, with mild hyperemesis and a urinary tract infection that grew out E. coli. What are the correct diagnosis codes?

   
   
   
   
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     Answer: O21.0 Mild hyperemesis gravidarum

     
     
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     O23.42 Unspecified infection of urinary tract in pregnancy Second Trimester

     
     
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     B96.20 Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere

     
     
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     Z3A.16 16 weeks’ gestation of pregnancy

   
   
   
   
3. 
   

   Patient is a 29-year-old G2P1 at 39 and 6/7 weeks’ gestation. She arrived in active labor to outpatient L&D. Patient labored for eight hours and delivered a live born male over intact perineum. What are the correct diagnosis codes?

   
   
   
   
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     Answer: O80 Encounter for full-term uncomplicated delivery

     
     
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     Z37.0 Outcome of delivery single live-born

   
   

The CPT coding system is maintained by the American Medical Association (AMA) and is the primary resource for coding within the OB/GYN hospitalist practice. However, the American Congress of Obstetricians and Gynecologists (ACOG), Society of Maternal Fetal Medicine (SMFM), and Society of Obstetric and Gynecologic Hospitalists (SOGH) are the key resources for developing good coding and billing procedures.

OB/GYN hospitalists do not code and bill in the same manner as a traditional OB/GYN practice. Hospitalists are not bound by the constraints of an OB global package and can bill their services in an unbundled fashion. They have the opportunity to bill for hospital admissions (both inpatient and outpatient) as a separately identifiable service since they are not the global OB provider. This means that the OB/GYN hospitalist can bill for hospital admissions, ancillary services such as Non-Stress Tests (NSTs), fetal ultrasounds, insertion of cervical dilators, delivery-only care, postpartum daily rounding services, and discharge services. OB/GYN hospitalists that are on standby can also bill for standby time, assistance at delivery, usage of ultrasound during delivery, placenta-only deliveries, laceration repairs, and many other services that traditional OB packages have included within global care.

Questions frequently arise whether one can bill for common scenarios encountered in an OB/GYN hospitalist practice. In addition to the coding/billing staff, organizations such as SOGH, ACOG, and SMFM can help find answers to these issues. The clinical documentation is crucial for good coding. The better your documentation, the more successful the practice will be in maintaining fiscal solvency. All clinical documentation must correlate to the diagnosis of the patient and support the medical necessity of diagnostic and therapeutic interventions and procedures performed. Good documentation does not necessarily have to be lengthy, but it should be clear and concise, support the diagnosis and procedures performed, and have a time notation when necessary.

Reciprocity agreements are common between global OB and OB/GYN hospitalist practices. If these are in effect, be sure to document in the medical and billing record whether the services you are providing are performed within the contractual guidelines of any reciprocity agreement.

In addition, time-based services can be a huge benefit for an OB/GYN hospitalist practice. When documenting time, be sure to notate the time spent face to face, or time spent on the floor in active care of the patient. However, any procedures you perform during this time are not counted in a time-based evaluation and management code.

As you proceed through the balance of this chapter, you will find coding guidelines for the majority of the nuts and bolts of an OB/GYN hospitalist practice. However, this list is not all-inclusive (Fig. 6-3).

THE SEVEN ESSENTIAL PARTS OF A CPT CODE

1. 
   

   CPT Code Number: In the CPT book, usually in the 50000 code-set range

   
   
2. 
   

   Type/Place of Service: Emergency Department/OB Outpatient/OB Inpatient

   
   
3. 
   

   New or Established Patient

   
   
4. 
   

   Number of Required Key Components (new patients require three of three key components; established patients require two of three key components)

   
   
5. 
   

   Definition of Key Components (History, Exam, Medical Decision-Making, and Time)

   
   
6. 
   

   Contributory Factors (other ancillary services needed or performed)

   
   
7. 
   

   Average Time Documented

KEY COMPONENTS OF E&M

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  History = Talk

  
  
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  Examination = Touch

  
  
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  Medical Decision-Making = Think

  
  
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  OR the usage Of Time

  
  
  
  
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    Time = Time spent face-to-face to include documented patient counseling, coordination of care, and documented patient and floor time