Understand Split OB GYN Billing to Avoid Duplicate Billing

Challenges of OB GYN Billing

Coding and billing for maternity obstetrical care are quite a bit different from the rest of the medical specialties. Maternity care services typically include antepartum care, delivery services, as well as 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 doesn’t end here, billing team has to deal to patients where split OB GYN billing is involved. In this article, we 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, but 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 is dealing only with routine antepartum care.
  • In most cases, the maternal-fetal specialist 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.
  • And while this may seem like concurrent care, it really 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 make a case for the obstetrician still billing 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 goes to see the specialist, that physician will bill the individual E/M visit (99202-99215), not antepartum care, and will be reporting 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 came across 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 along with the delivery and postpartum care.

  • When a patient changes insurance carriers in mid-pregnancy, the global obstetric code becomes obsolete. 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/or 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, also 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 in OB GYN billing and help you avoid any duplicate billing in such billing scenarios. To know more about our billing and coding services, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.