Coding is one of the complicated and most incompetently achieved processes for an OB/GYN practice. Most of the coders face multiple errors during claim transmission from the EDI end and claim denial from the insurance end. It creates an inability to earn income when the coding part of the practice is not monitored and audited on a regular basis.
The reason why these coding mistakes happen is lack of coders knowledge/certification, not following CMS guidelines on particular use of codes, educating on deleted and updated codes, not capturing accurate level of care and not sequencing diagnosis properly.
According to American Academy of Professional Coders, their survey states 200 samples of any claims an 80% of capturing incorrect codes altogether is not uncommon. Also 45% are under coded, 41% are over coded and 17% are part of services which are billed but not documented on the charges/records. Another survey by America’s Hidden Healthcare Crisis says that $100 billion are lost by healthcare professionals and facilities due to such coding and non-documented errors.
Some OB/GYN providers bring themselves the risk by over-coding the codes in order to increase the revenue of the services rendered artificially and not documented of such over-coding in the records. Also few physicians under code the billed diagnosis and tend to omit the services which are medically necessary for the patient, these physicians are subjected to CDI audits and are identified, not only these healthcare professionals pay huge amounts of fine to CMS. They also have dangers of getting their license barred or banned, or worse get incarcerated for federal charges. These physicians may never have their reputations built up as it used to be or never practice medicine ever again.
National Health Care Anti-Fraud Association has listed down the common areas of errors in OB/GYN coding:
Global Period billable and covered services:
Some of the OB/GYN services provided to the patient during a global period are often neglected that they are payable even when in a globally bundled scenario. The Usual postpartum and prenatal care are included under the global package and are not separately reimbursed. Other visits which are not related to the actual pregnancy visits and surgeries, such as STDs, vaginitis, yeast infections etc. are not included under the global package and are reimbursed separately. Illnesses or conditions which are not related to the pregnancy are billed separately during the time of treatment or service.
Say the postpartum is the reason for the patients visit and she decides to visit the OB/GYN physician in order to discuss the birth control treatment options/plans. In this case the physician is mandated to check the patient’s history and educates the patient about the birth control treatment options/plans. Patients chooses to go with the hormonal intrauterine device (IUD), now the provider places the order for the device and suggests the patient to return to another follow up appointment for the insertion of the device. This is how codes must be billed outside of the postpartum visit codes:
99213 to 24: Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period.
Z30.09: Encounter for other general counseling and advice on contraception. (Mentioned as the primary DX code and the sequencing are done accordingly).
Z30.014: Encounter for initial prescription of intrauterine contraceptive device.
Say a patient visits an OB/GYN physician for her prenatal routine visit and explains the condition of virginal discharge with odor. Then doctor proceeds for an exam and then suggests collecting culture for a wet prep and finally confirms the prognosis as acute vaginitis. Then the physician educates the patient about bacterial vaginosis and orders a treatment with clindamycin. This is how codes must be billed outside of the routine prenatal visit codes:
99213- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; Medical decision making of low complexity.
87210- Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps).
HCPCS Level II Q0111- Wet mounts, including preparations of vaginal, cervical or skin specimens (rather than 87210) for the wet prep.
N76.0- Acute vaginitis (mentioned as the primary DX code and the sequencing are done accordingly).
The OB/GYN physician must document clinical information of the visit on the encounter notes. If the physician sees a patient diagnosed and treated for conditions/problems outside of global period, but not seen in an E&M service level billed, notify the provider for corrections on the records.
Say a patient comes in for a postpartum visit. She has explains the condition to the OB/GYN physician stating high levels of depression and self-harming tendencies. Similar to the above mentioned physician examines entire patient’s history to determine whether the patients have had actual behavioral health symptoms before or just due to postpartum depression. Then the patient is referred to a psychologist by the OB/GYN physician and then patient is prescribed with antidepressants. The referring provider then provides a referral form and the patient visits the psychologist in another separate appointment. This is how codes must be billed outside of the postpartum visit codes:
99214 to 24: 24 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity.
F53.0: Postpartum depression (mentioned as the primary DX code and the sequencing are done accordingly).
Coding diagnosis for childbirth and deliveries:
Usually coders get confused of the many complications of child birth. It is the medical records handler or clinical documentation specialist’s responsibility to document the step by step labor procedures carefully in order for the coders to capture the accurate codes and bill a clean claim which eventually leads to effortless reimbursement from the payers. So let’s see some exact diagnosis and how to capture them during any child birth scenarios such as uncomplicated, complicated, caesarean and multiple delivery.
Usually the diagnosis used for full-term uncomplicated delivery is O80. This diagnosis is only used during the following criteria is met:
- Only used when the delivery is completely normal and should not be used even when episiotomy assistance is provided.
- Not used when instruments are used to manipulate the fetus.
- When the mother undergoes cephalic, spontaneous, vaginal delivery.
- Delivery outcome must be a single live birth where dx Z37.0 is uses.
- O80 dx code does not apply to stillbirths or multiple births (twins).
Caesarean and Complicated delivery:
If the OB/GYN physician fined any complication during the normal delivery then they should consider for a caesarean and should use the primary diagnosis for caesarean O82- single delivery by caesarean section, because the mother will be immediately transferred to surgery and do not waste their time in the labor ward. So the normal delivery will no longer be used as a primary diagnosis and will be changed as a 3rd or 4th depending upon the condition of the mother recorded in the medical records. If the complications differ, there are usually multiple diagnoses for caesarean which are:
Delivery by elective caesarean section
Delivery by emergency caesarean section
Delivery by caesarean hysterectomy
Other single delivery by caesarean section
Delivery by caesarean section, unspecified
In the case of complicated delivery and the coders find the reasons for the complications are not mentioned in the records, It is always a must to consult the rendering OB/GYN physician for the exact complications so that the diagnosis may be defined accordingly in the claims. Some of the complicated births and fetal manipulation techniques used during complicated delivery are:
Other assisted single delivery
Other assisted breech delivery
Other manipulation-assisted delivery
Delivery of viable fetus in abdominal pregnancy
Destructive operation for delivery
Other specified assisted single delivery
Assisted single delivery, unspecified
If the OB/GYN physician identifies the mother is expected multiple deliveries, the chances of delivering naturally is not possible. The physician usually considers or suggests the mother and father for a caesarean if the mother has other health conditions which could affect the natural birth. So the coders must refer the records for the exact primary diagnosis and capture the codes accordingly. Some of the multiple deliveries diagnosis is:
Multiple deliveries (Use additional code (O80-O83), if desired, to indicate the method of delivery of each fetus or infant)
Multiple deliveries, all spontaneous
Multiple deliveries, all by forceps and vacuum extractor
Multiple deliveries, all by caesarean section
Other multiple deliveries (Multiple deliveries by combination of methods)
Multiple delivery, unspecified
Outpatient OB/GYN services or procedures denials:
Not all OB/GYN services or procedures are inpatient most of the visits during pregnancy are outpatient visits and usually they are apart from the pregnancy and related to other conditions that only consulted with an OB/GYN physician.
Some of the outpatient codes which are usually overlooked and are not currently updated in the coding updates. These codes are incorrectly captured by the coders, it is denied as not a correct procedure according to NCCI edits are not relevant to the services rendered. These services/procedures use high tech devices and lab assistance to render.
Fluid collection drainage by catheter, image guided
retroperitoneal/peritoneal, Trans rectal/transvaginal
Insertion of vaginal ovoid/uterine tandem for clinical brachytherapy
Laparoscopic ablation of fibroids
Solutions and Resolutions:
If your OB/GYN clinic, health center or facility has their own revenue cycle team which coordinates with in-house coders, the director or manager of the revenue cycle is suggested to perform the following measures in order to keep their coders up to date. First and foremost they need to check whether their coders coding certification credentials are obtained for basic entry level and master level.
Organizations like AACP and AHIMA provide regular education and informative materials to licensed coders; key is to have them enrolled in such regular educational programs to keep informed. Some of the programs and materials they offer on a regular basis are:
- Audio seminars are provided by these organizations regularly on various topics throughout the year.
- Training programs using web based or webinars for greater understanding of medical record coding fundamentals.
- Novice to advanced topics for coding topics which are usually overlooked presented by master coders using web based live coaching.
- Coding publication materials subscription through manual mail.
- Online coding newsletters.
- Annual conferences and meetings.
We all know that managing an in-house RCM team is a stressful work for any OB/GYN practice manager or doctor. Outsourcing coding services for a practice will be a good management decision, because most coding and billing companies have highly experienced coders with master level certification. If your practice’s concern is their certification, you can always verify their license numbers with the respective coding education organization the coders have obtained certification. It not only shows the license start and end dates also it gives the practice owners reliability in their work.
Other benefits of outsourcing coding are their coding team’s hierarchy structure. Most coding teams in outsourcing companies have a coding manager, team leads, auditors and the coders themselves. So all coding work is monitored and “micro managed” through this hierarchy and delivers 99% quality of coding. These coders are also experienced in using various EHR/EMR which allows them to navigate with ease.
Outsourcing companies also use coding automation tools; these tools ensure automated checks after the manual auditing has been completed. These tools are integrated with the NCCI edits protocols and ICD-10 current updated versions.
So find a right outsourcing company for your OB/GYN coding and utilize their expertise while decreasing costs for work utilization and increase revenue by successfully decreasing coding denials for your OB/GYN practice specialty claims.