NAMAS Webinar Q&A: Specialty Auditing: OB/GYN 04/02/19

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Below are the questions received during our recent webinar, Specialty Auditing: OB/GYN originally presented on April 2, 2019. These questions have been answered by the webinar presenter, Grant Huang, CPC, CPMA.

Question 1: Auditing an OB flowsheet would be very helpful for those payers that bill per visit. Especially when it is a continuous record.
Answer 1: I agree, great idea! The groups I have worked with use a variant of the “Hollister” form that can make auditing very difficult and does not lend itself to supporting higher levels of service. We will incorporate this into future webinars on OB/GYN auditing.

Question 2: Can you tell me where you reference that a patient with pre-existing DM cannot separately billed for management of DM during the OB global period?
Answer 2:  This is actually a little complicated, so bear with me. If the preexisting problem is not related to the pregnancy, for example acute vaginitis, then it is always separately billable with an E/M code using modifier 25 and the appropriate non-obstetrical diagnosis code. So far, so good. But if the preexisting problem is complicating the pregnancy, then it should be addressed as part of the 13 antepartum visits included in the global OB package. Only if this preexisting problem is significant to the point where additional resources are used, would it be appropriate to separately bill. Both CPT and ACOG define additional resources as visits beyond the usual 13. For example, ACOG states in its procedural coding guide that “Additional visits (over the usual 13) to treat complications of the pregnancy are reported after the patient has delivered … The additional visits for the complications must be linked to an appropriate diagnosis code. Examples of these conditions are gestational diabetes and placenta previa.” In your question, you cited type 2 diabetes mellitus (DM). If this condition is not impacting the pregnancy, then I agree you can separately bill regardless of the 13 visits. But type 2 DM can definitely complicate the pregnancy, so I believe it would be correct to follow ACOG and CPT. But, whenever in doubt – check with your specific payer on their global OB policy.

Question 3: Could you explain the need for mod 25 in an audit for a code pair where there isn't an NCCI edit? (e.g., preventive exam billed w/EM for complaint at the same encounter) when the payer doesn't require it.
Answer 3: Remember, NCCI is maintained by CMS whereas the CPT codes and their requirements are set by the AMA. One of the challenges we face as auditors is knowing which guidelines take precedence in any given situation. The requirement for modifier 25 in this case comes from CPT. Of course, payers may or may not follow CPT at their discretion; however, for educational purposes I always try to set a conservative, i.e. high, standard. The CPT guidelines (E/M and Preventive Medicine Services chapter) state: “If an abnormality is encountered … and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.”

Question 4: Do the weeks of gestation Z3A.XX codes apply to abortion management? I don't always see this documented, maybe because it's difficult to discern during an abortive procedure like D&C. Or should I use the estimated gestational age from the H&P?
Answer 4: As long as you have the correct principal diagnosis code, such as O03.9 (complete or unspecified spontaneous abortion w/o complication), I don’t believe you need the weeks of gestation as secondary diagnoses for the dilation and evacuation code. The weeks of gestation secondary diagnoses are required primarily for the prenatal visits.

Question 5: For sample note # 1- what documentation is required to keep in the chart to code 96127?
Answer 5: CPT 96127 (brief emotional/behavioral assessment, with scoring and documentation, per standardized instrument) is a relatively new code and I have not seen much in the way of detailed LCDs from payers. So, we are mostly left with the CPT description, and that says 96127 requires that a standard survey instrument be used, scored, and the results documented. Based on our sample note, we do have the instrument specified (PHQ9), but the note does not give the specific score (PHQ9 has a point scale 0-27) and only says the results showed a “mild depressive disorder.” Thus I would say that the chart must also include the actual PHQ9 score in order to support 96127.

Question 6: How would you code a breast lump in the 12 o’clock position? UOQ or UIQ?
Answer 6: This has been a known issue with the breast quadrants, as there are four overlapping quadrants (12 o’clock, 3 o’clock, 6 o’clock, 9 o’clock). Hopefully future ICD-10 updates will offer a code-based solution. In the meantime, personally I think either UOQ or UIQ is supportable if the note says 12 o’clock position, and I would NOT use the unspecified code because the doctor wrote down an overlapping clock face position. Another possible solution is to pull the doctors aside, show them the breast quadrant diagram, and suggest that they write down a quadrant instead of giving a clock face, if they would be willing.

Question 7: I recently started auditing for OB services. I have come across charts where the patient delivered at a different hospital and now the prenatal visits are outside the global package but many of the office documentation is very brief. Can I include those "brief documentation" visits in the antepartum code 59425/ 59526?
Answer 7: It’s hard for me to say without seeing what constitutes “brief documentation” in these cases. According to CPT, the antepartum visit documentation should include:
o Initial prenatal hx and physical exam
o Subsequent prenatal hx and exam
o Recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis
o Any relevant assessment/plan for routine OB issues managed during each visit

Question 8: If a patient had a confirmed PG urine test at another provider but is seeing a new provider do you have to use the Z32.01 to start the global OB package?
Answer 8: If I understand this correctly, the patient has already gotten confirmation of pregnancy and as far as their insurance company is concerned, they’ve paid for confirmation already. Therefore, the global period has started, and for the initial prenatal visit, you do not need to use Z32.01 – instead use whatever is the appropriate pregnancy supervision code, plus weeks of gestation and any other appropriate secondary diagnoses. The involvement of different providers here doesn’t affect the billing as (presumably) the “new provider” is the one who would bill the global and there is no need to split it as the confirmation visit is not part of the global.

Question 9: Is it correct to code Q0091 to a commercial payer if just an E/M is done with a pap (patient came in for STD screening, but isn't up to date on pap)?
Answer 9: It will depend on the payer’s specific guidelines, but there is currently an active NCCI edit that would prevent Q0091 from being billed with either a new or established patient office visit. To separately bill, you would need to meet modifier 25 requirements and append -25 to the E/M code. In the scenario you describe, I believe you could bill for both and meet -25, provided the physician documents appropriately. Ideally, they would document in the assessment/plan that patient also was not up to date with the Pap and thus that was done in the same encounter. An STD-related diagnosis would be used with the E/M code and a screening diagnosis for the Pap, e.g. Z12.4.

Question 10-13: What is your reasoning for being able to bill New patient PE and a new patient E/M at the same visit? Referring to the first scenario.; Regarding the prevent with problem oriented, how do you split up the exam to arrive at the 99203? Since the comp exam is part of the preventive; would the problem visit be an established problem visit?; On pg 19 Preventive OB example, how can you use the exam for two different E/M codes? What exam components is he using for the new patient visit? Not feeling the answer at all.; Regarding Case #1: Wouldn’t the problem visit be billed with an established pt. E&M 99213 instead of 99203? I thought you could not bill both visits as new patients?
Answer to questions 10-13: This response addresses all the questions I received on this example, as there seems to be some confusion about a.) satisfying the exam requirements insofar as CPT says you can’t double-dip key components for multiple E/M services, and b.) why it’s appropriate to bill both codes at all.
 Comprehensive exam. First, I apologize for glazing over the exam – this was in an effort to try and limit the slide deck to correspond to a 60-minute webinar – I see now it was confusing since it feels “skipped.” When I stated that we would assume a comprehensive physical exam was documented, I really meant to say “let’s just assume the exam requirements were met.” That could mean 2 sets of exams dictated, or 1 exam with enough elements captured to satisfy both 99385 and 99203 without double-dipping. I didn’t get into the details on this because the intention was to illustrate a clinical scenario where both codes are billable, rather than dive into how each key component would be parsed (that would really be more appropriate for a webinar on E/M auditing or preventive services auditing).
 That said, it is possible to support both 99385 and 99203 with one physical exam, if it is very well documented. CPT makes it clear that the key components required for problem-oriented codes do NOT work in the same way for the preventive codes. CPT states: “The ‘comprehensive’ nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the ‘comprehensive’ examination required in Evaluation and Management codes 99201-99350.” In other words, the 99385 is not necessarily occupying the entirety of the comprehensive exam. If there is no separate exam for the problem-oriented code, we are allowed to divide elements of the existing exam to satisfy two separate codes, so long as we do NOT “double-dip.” A detailed exam is required for 99203, so under the 1995 guidelines we can get there with two systems, one of which is captured in a detailed fashion. In this specific example, we can count the psychiatric system exam and either constitutional or musculoskeletal system exam (both are relevant to psychiatric diagnoses and are part of the 1997 single specialty exam for psych). The remainder of the exam is attributed to the 99385. Ideally both the history and the exam exceed the requirements for a comprehensive history/exam under the 1995 E/M guidelines (for example, the ROS hits all 14 systems so that at least 2 systems can be attributed to 99203 and 10 systems can be attributed to the 99385, even though CPT doesn’t say 99385 needs 10 systems specifically). That said, there is nothing wrong with asking your physician to dictate 2 sets of exams to beef up your documentation in these scenarios.
 Why bill 2 codes? I stated in response to an earlier question that CPT explicitly allows a problem-oriented E/M code to be billed with the preventive code. That language from CPT is as follows: “If an abnormality is encountered … and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.” CPT states that only if the separate problem is too minor for there to be key components, would we limit the code to 99385 only: “An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported. In our example, the physician dedicated a significant portion of the HPI to the depression, then initiated an SSRI, fluoxetine (Prozac). This is clearly not an insignificant or trivial problem, in the opinion of the treating physician – that’s why he/she spent a noticeable effort on documenting it and then initiated a prescription anti-depressant. Therefore we have met the CPT requirement for billing a preventive E/M service and a problem-oriented E/M service.
 Can you bill 2 new patient codes in the same encounter? Finally, as for why can we bill 2 new patient E/M codes –there’s no rule that says you can’t do this, as long as the guidelines are met for a new patient. As long as this is truly a new patient, i.e. the patient has not seen the physician or another physician of the same specialty under the same tax ID in the last 3 years, then in that first encounter they are a new patient. The preventive service is not happening “before” the problem visit, nor vice versa. The patient cannot change states from new to established mid-visit. If they could, then under this logic you would face the inscrutable paradox of having to decide between billing 99385/99213 or 99395/99203. There is a CPT Assistant article that references this scenario, I believe it goes as far back as the 2006 edition, wherein it explicitly states that the patient can get a new patient preventive visit and a new patient sick visit service in the same encounter.

Question 14: What if one gravida results in twins with only one twin surviving? Is this still a G1P1?
Answer 14: After doing some research, the answer is that the notation system doesn’t really do a good job capturing this situation. I focused on gravidity/parity/abortus (GPA) notation as it is the most commonly seen in OB/GYN notes, and under this system, a woman’s first pregnancy that results in twins, where only one child survives, will be either G1P1A0 or G1P1A1, depending on whether the non-surviving child is lost prior to 20 weeks. If one twin is determined to have miscarried before 20 weeks, we can add A1 for one abortus. If both twins are delivered but one twin was stillborn, it is still G1P1.
 If we use the longer GTPAL notation, we can describe this situation a bit better, but still not perfectly.
o Gravidity – number of pregnancies, with twins counting as one
o Term births – number of pregnancies carried to at least 37 weeks /w delivery
o Preterm births – number of pregnancies carried to 20-36 weeks /w delivery
o Abortus – number of pregnancies /w delivery prior to 20 weeks
o Living children – number of individual living children
 So, with GTPAL we would have G1-T1-P0-A1-L1 if the twin was lost prior to 20 weeks. Unfortunately if the twin is instead stillborn and both twins are delivered after 37 weeks, we would have G1-T1-P0-A0-L1, which is indistinguishable from a first pregnancy without twins, with a full-term delivery and resulting in one living child.
 The issue is that twins count as one pregnancy, twin delivery is still counted as one delivery (whether full term or preterm), and abortus is still counted as one delivery before 20 weeks regardless of number of fetuses lost.

Question 15: What if the patient sees another provider (family practice or internal medicine) and they bill the preventive service code? Should the OB/GYN still report another preventive service in the same year?
Answer 15: This was answered on the call, but essentially, it’s entirely dependent on payer. If the payer distinguishes a general preventive physical from a GYN well-woman visit, then both providers may report a preventive service, using different preventive diagnoses (e.g., Z00.00 for the family practitioner, Z01.419 for the OB/GYN). Usually the OB/GYN is able to convert the well-woman visit to some sort of OB/GYN problem visit, for example even with no acute complaints there could be discussion of birth control options (using the diagnosis code series Z30.XX).

Question 16: Why would Preventive care codes (99381-99397) be used for a Well-woman visit with commercial payers have policies stating G0101 and Q0091 should be used?
Answer 16: In our line of work, the specific payer reimbursing a claim generally gets the final word. If a commercial payer has a policy stating they pay only for G0101 and Q0091, then you would follow that policy. However, there are certainly commercial plans that allow 99381-99397 for a well-woman visit utilizing the GYN encounter diagnosis (Z01.411/419). For example, Moda Health follows G0101/Q0091 for its Medicare Advantage (MA) plans, but for its purely private plans it allows 99381-99397. Remember that commercial payers with MA plans are obligated to follow Medicare Part B rules in most situations, but those same commercial payers offer their own private plans that are free from CMS guidelines.
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