Challenges of OB-GYN Billing
Coding and billing for maternity obstetrical care are quite different from the other medical specialties. Maternity care services typically include antepartum care, delivery services, and postpartum care. Depending on the patient’s circumstances and insurance carrier, the provider can either submit all rendered services for the entire nine months of services on one CMS-1500 claim form or submit claims based on an itemization of maternity care service. The challenges of maternity obstetrical care billing don’t end here; the billing team has to deal with patients with split OB-GYN billing. This blog considered two billing scenarios where split OB-GYN billing is required to avoid duplicate billing.
Multiple Providers Render Maternity Care
Assume a scenario where multiple providers render portions of maternity care for the same patient. In such scenarios, one physician treats the patient at the beginning of her OB care. Still, as she develops complications and is referred to a specialist for the remainder of her care, you need to split billing to avoid duplicate billing.
- While billing in such scenarios, check whether the obstetrician and the specialist are seeing the patient for the same condition, which would be concurrent care. Or the specialist is dealing only with the complication while the obstetrician only deals with routine antepartum care.
- The maternal-fetal specialist usually sees her once or twice for the complication and sends her back to the obstetrician for the rest of the care. Later in the pregnancy, another complication arises, and she goes back to the maternal-fetal specialist.
- While this may seem like concurrent care, it is not because the physicians are different, the diagnosis codes being used are different, and the regular obstetrician will bill for the routine antepartum services only. This means that they are not duplicating services.
- If this is the situation, you could argue that the obstetrician should still bill the global obstetric package if he goes on to deliver the baby and take care of the patient in the postpartum period because he is providing routine antepartum care.
- When the patient sees the specialist, that physician will bill the individual E/M visit (99202-99215), not antepartum care, and will report the complication as the diagnosis. Alternatively, you could make a case for splitting the global package and having the obstetrician just bill for the antepartum care alone using 59425 (Antepartum care only; 4-6 visits) or 59426 (Antepartum care only; 7 or more visits) if he transfers care to the specialist for the rest of the pregnancy.
Switched Insurance Carriers Mid-Pregnancy
You might encounter a scenario where an obstetric patient changes her insurance carrier mid-pregnancy. Let’s say an obstetric patient attended 11 visits and then she changed her insurance carrier, she is still antepartum with possibly 15 more visits to go. This is a split OB-GYN billing scenario where you have to split the bill among two payers and the delivery and postpartum care.
- The global obstetric code becomes obsolete when a patient changes insurance carriers in mid-pregnancy. You have to 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.
- In the above split OB GYN billing scenario where an obstetric patient attended 11 visits and then she changed her insurance carrier, you should bill 59426 (Antepartum care only; 7 or more visits) to the first insurance company and 59425 (Antepartum care only; 4-6 visits) to the second if four to six visits are its responsibility. If, by the time she delivers, your OB-GYN sees her only three times under the second insurer, you should report the appropriate established patient E/M service code (for example, 99212) for each visit instead of using 59425.
- In addition, you should report the appropriate code for delivery with postpartum care — such as 59410 (Vaginal delivery only [with or without episiotomy and forceps), including postpartum care) to the second payer.
- In case of any confusion, always talk to insurance carriers and get their requests in writing. Inform the insurance plan’s medical director about the recommendations and the implications for incorrect coding.
We shared information on split OB-GYN billing for provider education. You can always refer to billing guidelines or talk to an insurance rep for detailed guidance. Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services.
We can assist you with OB-GYN Billing and help you avoid duplicate billing in such scenarios. To learn more about our billing and coding services, email us at info@medicalbillersandcoders.com or call us at 888-357-3226.
FAQs
Split OB GYN billing refers to the process of dividing obstetric and gynecologic care into separate billing components. This can happen when different providers handle different parts of a patient’s care, such as prenatal visits, delivery, and postpartum care.
Understanding split billing is crucial to avoid duplicate billing and ensure accurate reimbursement. It helps healthcare providers correctly bill for each component of care without overcharging patients or insurance companies.
Common components of OB GYN care that might be billed separately include prenatal visits, laboratory tests, ultrasounds, delivery (vaginal or cesarean), and postpartum care. Each of these services may require individual billing codes.
Duplicate billing can occur when the same service is billed more than once, either by the same provider or different providers. This often happens due to miscommunication, lack of coordination, or errors in the billing process.
Strategies to prevent duplicate billing include:
1. Ensuring clear communication and coordination among all providers involved in a patient’s care.
2. Using accurate and detailed documentation.
3. Regularly auditing billing practices to identify and correct errors.
4. Implementing robust billing software that flags potential duplicate entries.
