Melanie Witt, RN, CPC-OGS, MA

Q Is there a code for a 3D gyn ultrasound, for example, to detect endometriosis? Or can you only bill the 76856 code (ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete)?

A As it happens, CPT added new codes this year to allow billing for 3D ultrasound: 76376 and 76377 (right). The 3D code is billed in addition to the basic service, which in your example is 76856. However, keep in mind that many payers still consider 3D investigational and will not pay without strong medical necessity. You should not be routinely billing for this technology.

Q Is there a code for a 3D gyn ultrasound, for example, to detect endometriosis? Or can you only bill the 76856 code (ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete)?

A As it happens, CPT added new codes this year to allow billing for 3D ultrasound: 76376 and 76377 (right). The 3D code is billed in addition to the basic service, which in your example is 76856. However, keep in mind that many payers still consider 3D investigational and will not pay without strong medical necessity. You should not be routinely billing for this technology.

Q Is there a code for a 3D gyn ultrasound, for example, to detect endometriosis? Or can you only bill the 76856 code (ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete)?

A As it happens, CPT added new codes this year to allow billing for 3D ultrasound: 76376 and 76377 (right). The 3D code is billed in addition to the basic service, which in your example is 76856. However, keep in mind that many payers still consider 3D investigational and will not pay without strong medical necessity. You should not be routinely billing for this technology.

Q At 19 weeks’ gestation, our patient presented to the emergency room leaking amniotic fluid. The umbilical cord was protruding through the vagina and the fetus was in breech presentation. She was not in active labor. Ultrasound showed no amniotic fluid around the fetus and no fetal heart rate. We induced labor, which lasted 16 hours. How can we bill?

A If this labor was induced with misoprostol or another cervical dilator, the correct code is 59855 (induced abortion, by one or more vaginal suppositories [eg, prostaglandin] with or without cervical dilation [eg, laminaria], including hospital admission and visits, delivery of fetus and secundines). It is not appropriate to bill for delivery unless the fetus is older than 20 weeks 0 days gestation or is born alive, which was not the case here.

Induction with IV oxytocin would be classified as medical management of an abortion. Under CPT rules and ACOG guidelines, you would bill only for the evaluation and management (E/M) services. However, this means you would be billing for the hospital admission, subsequent care, and, prior to delivery, prolonged physician services. In this case you would report the hospital prolonged care codes that account for the actual time you spent with the patient managing her labor, as long as that time exceeds by 30 minutes the typical time of the E/M code you reported (TABLE).

For instance, if she is admitted at 10 PM on day 1 and delivers on day 2 at 2 PM, with your having documented that you spent a total of 2 hours at the patient’s bedside on day 1 and 8 hours at the patient’s bedside on day 2, you could bill as follows:

Day 1: Hospital admission (eg, 99222, requiring comprehensive history and exam and moderate medical decision-making with a typical time of 50 minutes)

Prolonged services on day 1: 120 minutes total –50 minutes=70 minutes of prolonged service. Bill code 99356 (first 60 minutes), but no additional code for the last 10 minutes of prolonged service.

Day 2: Subsequent hospital care (eg, 99232 requiring an expanded problem, focused history or exam with moderate complexity of medical decision-making with a typical time of 25 minutes).

Prolonged services for 8 hours on day 2: 480 minutes total –25 minutes=455 minutes of prolonged service; bill code 99356 (first 60 minutes), and 99357 with a quantity of 13 for the remaining 395 minutes.

TABLE

You have to do the math: Coding prolonged physician services

TOTAL TIME W/PATIENT	BASIC SERVICE	BILLABLE PROLONGED SERVICE	PROLONGED SERVICES WITH CODES REPORTED
Day 1 120 minutes	99222 (50 minutes)	120 min –50 min=70 minutes	99356 for first 60 minutes, but no extra codes for last 10 minutes
Day 2 480 minutes	99232 (25 minutes)	480 min –25 min=455 minutes	99356 for first 60 minutes; 455 min –60 minutes=395 minutes 99357×13 for remaining time (13 times for each 30-minute increment)

Q At 19 weeks’ gestation, our patient presented to the emergency room leaking amniotic fluid. The umbilical cord was protruding through the vagina and the fetus was in breech presentation. She was not in active labor. Ultrasound showed no amniotic fluid around the fetus and no fetal heart rate. We induced labor, which lasted 16 hours. How can we bill?

A If this labor was induced with misoprostol or another cervical dilator, the correct code is 59855 (induced abortion, by one or more vaginal suppositories [eg, prostaglandin] with or without cervical dilation [eg, laminaria], including hospital admission and visits, delivery of fetus and secundines). It is not appropriate to bill for delivery unless the fetus is older than 20 weeks 0 days gestation or is born alive, which was not the case here.

Induction with IV oxytocin would be classified as medical management of an abortion. Under CPT rules and ACOG guidelines, you would bill only for the evaluation and management (E/M) services. However, this means you would be billing for the hospital admission, subsequent care, and, prior to delivery, prolonged physician services. In this case you would report the hospital prolonged care codes that account for the actual time you spent with the patient managing her labor, as long as that time exceeds by 30 minutes the typical time of the E/M code you reported (TABLE).

For instance, if she is admitted at 10 PM on day 1 and delivers on day 2 at 2 PM, with your having documented that you spent a total of 2 hours at the patient’s bedside on day 1 and 8 hours at the patient’s bedside on day 2, you could bill as follows:

Day 1: Hospital admission (eg, 99222, requiring comprehensive history and exam and moderate medical decision-making with a typical time of 50 minutes)

Prolonged services on day 1: 120 minutes total –50 minutes=70 minutes of prolonged service. Bill code 99356 (first 60 minutes), but no additional code for the last 10 minutes of prolonged service.

Day 2: Subsequent hospital care (eg, 99232 requiring an expanded problem, focused history or exam with moderate complexity of medical decision-making with a typical time of 25 minutes).

Prolonged services for 8 hours on day 2: 480 minutes total –25 minutes=455 minutes of prolonged service; bill code 99356 (first 60 minutes), and 99357 with a quantity of 13 for the remaining 395 minutes.

TABLE

You have to do the math: Coding prolonged physician services

TOTAL TIME W/PATIENT	BASIC SERVICE	BILLABLE PROLONGED SERVICE	PROLONGED SERVICES WITH CODES REPORTED
Day 1 120 minutes	99222 (50 minutes)	120 min –50 min=70 minutes	99356 for first 60 minutes, but no extra codes for last 10 minutes
Day 2 480 minutes	99232 (25 minutes)	480 min –25 min=455 minutes	99356 for first 60 minutes; 455 min –60 minutes=395 minutes 99357×13 for remaining time (13 times for each 30-minute increment)

Q At 19 weeks’ gestation, our patient presented to the emergency room leaking amniotic fluid. The umbilical cord was protruding through the vagina and the fetus was in breech presentation. She was not in active labor. Ultrasound showed no amniotic fluid around the fetus and no fetal heart rate. We induced labor, which lasted 16 hours. How can we bill?

A If this labor was induced with misoprostol or another cervical dilator, the correct code is 59855 (induced abortion, by one or more vaginal suppositories [eg, prostaglandin] with or without cervical dilation [eg, laminaria], including hospital admission and visits, delivery of fetus and secundines). It is not appropriate to bill for delivery unless the fetus is older than 20 weeks 0 days gestation or is born alive, which was not the case here.

Induction with IV oxytocin would be classified as medical management of an abortion. Under CPT rules and ACOG guidelines, you would bill only for the evaluation and management (E/M) services. However, this means you would be billing for the hospital admission, subsequent care, and, prior to delivery, prolonged physician services. In this case you would report the hospital prolonged care codes that account for the actual time you spent with the patient managing her labor, as long as that time exceeds by 30 minutes the typical time of the E/M code you reported (TABLE).

For instance, if she is admitted at 10 PM on day 1 and delivers on day 2 at 2 PM, with your having documented that you spent a total of 2 hours at the patient’s bedside on day 1 and 8 hours at the patient’s bedside on day 2, you could bill as follows:

Day 1: Hospital admission (eg, 99222, requiring comprehensive history and exam and moderate medical decision-making with a typical time of 50 minutes)

Prolonged services on day 1: 120 minutes total –50 minutes=70 minutes of prolonged service. Bill code 99356 (first 60 minutes), but no additional code for the last 10 minutes of prolonged service.

Day 2: Subsequent hospital care (eg, 99232 requiring an expanded problem, focused history or exam with moderate complexity of medical decision-making with a typical time of 25 minutes).

Prolonged services for 8 hours on day 2: 480 minutes total –25 minutes=455 minutes of prolonged service; bill code 99356 (first 60 minutes), and 99357 with a quantity of 13 for the remaining 395 minutes.

TABLE

You have to do the math: Coding prolonged physician services

TOTAL TIME W/PATIENT	BASIC SERVICE	BILLABLE PROLONGED SERVICE	PROLONGED SERVICES WITH CODES REPORTED
Day 1 120 minutes	99222 (50 minutes)	120 min –50 min=70 minutes	99356 for first 60 minutes, but no extra codes for last 10 minutes
Day 2 480 minutes	99232 (25 minutes)	480 min –25 min=455 minutes	99356 for first 60 minutes; 455 min –60 minutes=395 minutes 99357×13 for remaining time (13 times for each 30-minute increment)

Q A patient was admitted on December 22, at 35 weeks, for a diagnosis of oligohydramnios. The maternal-fetal medicine (MFM) specialist tried unsuccessfully to do an amniocentesis and then decided to induce labor on December 23. The patient delivered on December 24. Our payer is denying all 3 hospital visits as global.

Would it be appropriate to add a –57 modifier (decision to do surgery) to the admission, and if so, what modifier should be added to subsequent hospital visits?

A Generally, you will not get paid for a hospital visit on the day of the delivery, and you need to realize that the admission prior to delivery is also included as part of the global.

But some payers will acknowledge that the patient is being treated for a complication of the pregnancy and not for admission for delivery and will allow both the admission and any subsequent visits except on the day of delivery.

The problem with any modifier prior to delivery with global obstetric care is that “delivery” is the inevitable outcome of the care, so the modifier –57, in my opinion, is not appropriate in this setting for the physician who is providing the global care. If the MFM specialist has not been providing maternity care and then determines that an emergency delivery must be performed, modifier –57 might be warranted. There are no other applicable modifiers for the care prior to delivery.

I suggest that you appeal the denial. Explain that the admission was not planned, and the reason for admission and care on the second day was for a complication of pregnancy, not labor management.

Q A patient was admitted on December 22, at 35 weeks, for a diagnosis of oligohydramnios. The maternal-fetal medicine (MFM) specialist tried unsuccessfully to do an amniocentesis and then decided to induce labor on December 23. The patient delivered on December 24. Our payer is denying all 3 hospital visits as global.

Would it be appropriate to add a –57 modifier (decision to do surgery) to the admission, and if so, what modifier should be added to subsequent hospital visits?

A Generally, you will not get paid for a hospital visit on the day of the delivery, and you need to realize that the admission prior to delivery is also included as part of the global.

But some payers will acknowledge that the patient is being treated for a complication of the pregnancy and not for admission for delivery and will allow both the admission and any subsequent visits except on the day of delivery.

The problem with any modifier prior to delivery with global obstetric care is that “delivery” is the inevitable outcome of the care, so the modifier –57, in my opinion, is not appropriate in this setting for the physician who is providing the global care. If the MFM specialist has not been providing maternity care and then determines that an emergency delivery must be performed, modifier –57 might be warranted. There are no other applicable modifiers for the care prior to delivery.

I suggest that you appeal the denial. Explain that the admission was not planned, and the reason for admission and care on the second day was for a complication of pregnancy, not labor management.

Q A patient was admitted on December 22, at 35 weeks, for a diagnosis of oligohydramnios. The maternal-fetal medicine (MFM) specialist tried unsuccessfully to do an amniocentesis and then decided to induce labor on December 23. The patient delivered on December 24. Our payer is denying all 3 hospital visits as global.

Would it be appropriate to add a –57 modifier (decision to do surgery) to the admission, and if so, what modifier should be added to subsequent hospital visits?

A Generally, you will not get paid for a hospital visit on the day of the delivery, and you need to realize that the admission prior to delivery is also included as part of the global.

But some payers will acknowledge that the patient is being treated for a complication of the pregnancy and not for admission for delivery and will allow both the admission and any subsequent visits except on the day of delivery.

The problem with any modifier prior to delivery with global obstetric care is that “delivery” is the inevitable outcome of the care, so the modifier –57, in my opinion, is not appropriate in this setting for the physician who is providing the global care. If the MFM specialist has not been providing maternity care and then determines that an emergency delivery must be performed, modifier –57 might be warranted. There are no other applicable modifiers for the care prior to delivery.

I suggest that you appeal the denial. Explain that the admission was not planned, and the reason for admission and care on the second day was for a complication of pregnancy, not labor management.

Q A patient’s insurance company bundles an ultrasound procedure with a consultation, and quotes Medicare rules as the basis. For instance, we bill 99242 (Office consultation; expanded problem focused history and exam with straightforward medical decision-making) with 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) and the services are being provided by a maternal-fetal specialist.

I have appealed many times, but they refuse to pay for both. Do you have any suggestions?

A My first suggestion is that you inform ACOG’s Department of Practice Management about this problem. For more information, see http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=1932. ACOG has been helpful to many practices in the past on just such payment issues.

The payer is not correct in this case. Medicare rules stipulate that a consultation can be billed with a diagnostic procedure on the same day and both will be paid. You should ask for the exact reference to the Medicare rule they are using.

In addition, I suggest that you add a modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code you are billing. This tactic will clearly identify the E/M service as significant and separate from the diagnostic test.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q A patient’s insurance company bundles an ultrasound procedure with a consultation, and quotes Medicare rules as the basis. For instance, we bill 99242 (Office consultation; expanded problem focused history and exam with straightforward medical decision-making) with 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) and the services are being provided by a maternal-fetal specialist.

I have appealed many times, but they refuse to pay for both. Do you have any suggestions?

A My first suggestion is that you inform ACOG’s Department of Practice Management about this problem. For more information, see http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=1932. ACOG has been helpful to many practices in the past on just such payment issues.

The payer is not correct in this case. Medicare rules stipulate that a consultation can be billed with a diagnostic procedure on the same day and both will be paid. You should ask for the exact reference to the Medicare rule they are using.

In addition, I suggest that you add a modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code you are billing. This tactic will clearly identify the E/M service as significant and separate from the diagnostic test.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q A patient’s insurance company bundles an ultrasound procedure with a consultation, and quotes Medicare rules as the basis. For instance, we bill 99242 (Office consultation; expanded problem focused history and exam with straightforward medical decision-making) with 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) and the services are being provided by a maternal-fetal specialist.

I have appealed many times, but they refuse to pay for both. Do you have any suggestions?

A My first suggestion is that you inform ACOG’s Department of Practice Management about this problem. For more information, see http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=1932. ACOG has been helpful to many practices in the past on just such payment issues.

The payer is not correct in this case. Medicare rules stipulate that a consultation can be billed with a diagnostic procedure on the same day and both will be paid. You should ask for the exact reference to the Medicare rule they are using.

In addition, I suggest that you add a modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code you are billing. This tactic will clearly identify the E/M service as significant and separate from the diagnostic test.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can we bill for a 3-dimensional (3D) sonogram (76375), a transvaginal sonogram (76830), and a hysterosonogram at the same encounter or session? Our physicians do both the injection procedure (58340) and the ultrasound component (76831) and the 3D as well because they say they get a better picture.

A Your question involves 3 issues that I will address separately.

Transvaginal ultrasound

This procedure is included as part of 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). Transvaginal ultrasound should not be billed in addition unless it was performed to document a problem not related to the hysterosonogram. The ACOG coding manual agrees; it indicates that a transvaginal ultrasound should not be reported separately because it is included in the global service when performed. Since the Correct Coding Initiative (CCI) also bundles this code combination, you could bill it only if it was done during a separate session. A modifier -59 (Distinct procedural service) would be added to 76831 because this procedure is bundled into the code for the transvaginal ultrasound.

3D ultrasound

Your second coding problem is performing a 3D ultrasound at the time of the hysterosonogram. Here, there are 2 issues: insurance coverage and billing.

Many payers do not reimburse for 3D ultrasound because they consider it experimental—and none reimburse 3D ultrasound when done routinely. Medical necessity must be established for 3D rendering. Be sure to inform your patients that this procedure may not be covered by their insurance company, so that they can make an informed choice.

Billing

The CPT code you indicated, 76375, has been replaced by 2 new codes:

• Code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) and
  
• Code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation).
  

CPT indicates that in order to bill either of these 2 new codes, a basic scan must be reported in addition. These 2 codes also require “concurrent physician supervision of the image postprocessing 3D manipulation.”

CPT does not stipulate which codes can serve as the basic scan, but as 76831 is an ultrasound procedure, the payer may allow it to be used in this fashion.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can we bill for a 3-dimensional (3D) sonogram (76375), a transvaginal sonogram (76830), and a hysterosonogram at the same encounter or session? Our physicians do both the injection procedure (58340) and the ultrasound component (76831) and the 3D as well because they say they get a better picture.

A Your question involves 3 issues that I will address separately.

Transvaginal ultrasound

This procedure is included as part of 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). Transvaginal ultrasound should not be billed in addition unless it was performed to document a problem not related to the hysterosonogram. The ACOG coding manual agrees; it indicates that a transvaginal ultrasound should not be reported separately because it is included in the global service when performed. Since the Correct Coding Initiative (CCI) also bundles this code combination, you could bill it only if it was done during a separate session. A modifier -59 (Distinct procedural service) would be added to 76831 because this procedure is bundled into the code for the transvaginal ultrasound.

3D ultrasound

Your second coding problem is performing a 3D ultrasound at the time of the hysterosonogram. Here, there are 2 issues: insurance coverage and billing.

Many payers do not reimburse for 3D ultrasound because they consider it experimental—and none reimburse 3D ultrasound when done routinely. Medical necessity must be established for 3D rendering. Be sure to inform your patients that this procedure may not be covered by their insurance company, so that they can make an informed choice.

Billing

The CPT code you indicated, 76375, has been replaced by 2 new codes:

• Code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) and
  
• Code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation).
  

CPT indicates that in order to bill either of these 2 new codes, a basic scan must be reported in addition. These 2 codes also require “concurrent physician supervision of the image postprocessing 3D manipulation.”

CPT does not stipulate which codes can serve as the basic scan, but as 76831 is an ultrasound procedure, the payer may allow it to be used in this fashion.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can we bill for a 3-dimensional (3D) sonogram (76375), a transvaginal sonogram (76830), and a hysterosonogram at the same encounter or session? Our physicians do both the injection procedure (58340) and the ultrasound component (76831) and the 3D as well because they say they get a better picture.

A Your question involves 3 issues that I will address separately.

Transvaginal ultrasound

This procedure is included as part of 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). Transvaginal ultrasound should not be billed in addition unless it was performed to document a problem not related to the hysterosonogram. The ACOG coding manual agrees; it indicates that a transvaginal ultrasound should not be reported separately because it is included in the global service when performed. Since the Correct Coding Initiative (CCI) also bundles this code combination, you could bill it only if it was done during a separate session. A modifier -59 (Distinct procedural service) would be added to 76831 because this procedure is bundled into the code for the transvaginal ultrasound.

3D ultrasound

Your second coding problem is performing a 3D ultrasound at the time of the hysterosonogram. Here, there are 2 issues: insurance coverage and billing.

Many payers do not reimburse for 3D ultrasound because they consider it experimental—and none reimburse 3D ultrasound when done routinely. Medical necessity must be established for 3D rendering. Be sure to inform your patients that this procedure may not be covered by their insurance company, so that they can make an informed choice.

Billing

The CPT code you indicated, 76375, has been replaced by 2 new codes:

• Code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) and
  
• Code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation).
  

CPT indicates that in order to bill either of these 2 new codes, a basic scan must be reported in addition. These 2 codes also require “concurrent physician supervision of the image postprocessing 3D manipulation.”

CPT does not stipulate which codes can serve as the basic scan, but as 76831 is an ultrasound procedure, the payer may allow it to be used in this fashion.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can I bill a nonstress test (NST) 59025 with TC (Technical component) as a modifier?

A A physician never uses the -TC modifier, even if he or she personally performed the NST. If this procedure is performed in the hospital, the -TC modifier is reported by the hospital for the use of the equipment.

The physician reports the service with modifier -26 (Professional component).

If the procedure is performed in the office setting and the physician owns the equipment, code 59025 is billed without modifiers, as it represents both technical and professional components.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can I bill a nonstress test (NST) 59025 with TC (Technical component) as a modifier?

A A physician never uses the -TC modifier, even if he or she personally performed the NST. If this procedure is performed in the hospital, the -TC modifier is reported by the hospital for the use of the equipment.

The physician reports the service with modifier -26 (Professional component).

If the procedure is performed in the office setting and the physician owns the equipment, code 59025 is billed without modifiers, as it represents both technical and professional components.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can I bill a nonstress test (NST) 59025 with TC (Technical component) as a modifier?

A A physician never uses the -TC modifier, even if he or she personally performed the NST. If this procedure is performed in the hospital, the -TC modifier is reported by the hospital for the use of the equipment.

The physician reports the service with modifier -26 (Professional component).

If the procedure is performed in the office setting and the physician owns the equipment, code 59025 is billed without modifiers, as it represents both technical and professional components.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient presents to the hospital for preterm labor and is seen within 23 hours, which observation codes are appropriate: 99217–99220 (Initial observation care with discharge on second day) or 99234–99236 (Observation or inpatient care services including admission and discharge on the same day)?

There is no designated area in our hospital for 99217–99220, if I understand the coding book correctly.

A The code choice depends on when the services took place.

No designated place in the hospital is required in order to bill the observation codes, but the physician should state in the record that the patient is being kept for observation.

If the patient is “admitted and discharged” from observation care on the same calendar date, you bill the codes 99234–99236. If she is admitted on day 1 and discharged on day 2, then go with the 99217–99220 codes. Some payers have a time requirement for you to be able to bill for observation care, but many do not. if you cannot bill for observation care, then the default is the outpatient E/M codes, 99201–99215.

Remember these requirements for observation care:

• The minimum documentation is a detailed history and detailed exam with any level of medical decision-making (straightforward, low, moderate, or high complexity). If you fail to document both at the minimum level, you cannot use an observation code.
  
• The physician must physically see the patient on the date of admission and discharge in order to bill for observation care.
  

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient presents to the hospital for preterm labor and is seen within 23 hours, which observation codes are appropriate: 99217–99220 (Initial observation care with discharge on second day) or 99234–99236 (Observation or inpatient care services including admission and discharge on the same day)?

There is no designated area in our hospital for 99217–99220, if I understand the coding book correctly.

A The code choice depends on when the services took place.

No designated place in the hospital is required in order to bill the observation codes, but the physician should state in the record that the patient is being kept for observation.

If the patient is “admitted and discharged” from observation care on the same calendar date, you bill the codes 99234–99236. If she is admitted on day 1 and discharged on day 2, then go with the 99217–99220 codes. Some payers have a time requirement for you to be able to bill for observation care, but many do not. if you cannot bill for observation care, then the default is the outpatient E/M codes, 99201–99215.

Remember these requirements for observation care:

• The minimum documentation is a detailed history and detailed exam with any level of medical decision-making (straightforward, low, moderate, or high complexity). If you fail to document both at the minimum level, you cannot use an observation code.
  
• The physician must physically see the patient on the date of admission and discharge in order to bill for observation care.
  

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient presents to the hospital for preterm labor and is seen within 23 hours, which observation codes are appropriate: 99217–99220 (Initial observation care with discharge on second day) or 99234–99236 (Observation or inpatient care services including admission and discharge on the same day)?

There is no designated area in our hospital for 99217–99220, if I understand the coding book correctly.

A The code choice depends on when the services took place.

No designated place in the hospital is required in order to bill the observation codes, but the physician should state in the record that the patient is being kept for observation.

If the patient is “admitted and discharged” from observation care on the same calendar date, you bill the codes 99234–99236. If she is admitted on day 1 and discharged on day 2, then go with the 99217–99220 codes. Some payers have a time requirement for you to be able to bill for observation care, but many do not. if you cannot bill for observation care, then the default is the outpatient E/M codes, 99201–99215.

Remember these requirements for observation care:

• The minimum documentation is a detailed history and detailed exam with any level of medical decision-making (straightforward, low, moderate, or high complexity). If you fail to document both at the minimum level, you cannot use an observation code.
  
• The physician must physically see the patient on the date of admission and discharge in order to bill for observation care.
  

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q One of our doctors saw a new patient in labor and delivery, and then she was seen in our office for a more extensive exam and ultrasound on the same day, but by a different doctor. Normally I would bill both with a -59 modifier (Distinct procedural service) assigned to an evaluation-and-management (E/M) code, but I was recently told that the -59 modifier should not be assigned to an E/M code. How should I bill for these 2 separate encounters?

A You are correct. While the modifier -59 may be assigned when a distinct and separate service was provided on the same date of service, such as when there is a separate patient encounter, the services referred to in the CPT guidelines are medicine and procedural services, not E/M services. An article in the American Medical Association’s CPT Assistant (January 1999) clarified that the modifier -59 may not be appended to E/M services.

If the patient is seen for the same reason and the physicians are considered the same under the payer’s rules, bill only 1 E/M service for that day, but take into account all of the care the patient received during both encounters to select the right E/M service level. The ultrasound, of course, will be billed as well.

If the payer allows more than 1 encounter on the same day, the second encounter in the office must be reported as an established patient service, since a new patient service applies to the first encounter that day.

There are no appropriate modifiers that can be added to the second E/M service.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q One of our doctors saw a new patient in labor and delivery, and then she was seen in our office for a more extensive exam and ultrasound on the same day, but by a different doctor. Normally I would bill both with a -59 modifier (Distinct procedural service) assigned to an evaluation-and-management (E/M) code, but I was recently told that the -59 modifier should not be assigned to an E/M code. How should I bill for these 2 separate encounters?

A You are correct. While the modifier -59 may be assigned when a distinct and separate service was provided on the same date of service, such as when there is a separate patient encounter, the services referred to in the CPT guidelines are medicine and procedural services, not E/M services. An article in the American Medical Association’s CPT Assistant (January 1999) clarified that the modifier -59 may not be appended to E/M services.

If the patient is seen for the same reason and the physicians are considered the same under the payer’s rules, bill only 1 E/M service for that day, but take into account all of the care the patient received during both encounters to select the right E/M service level. The ultrasound, of course, will be billed as well.

If the payer allows more than 1 encounter on the same day, the second encounter in the office must be reported as an established patient service, since a new patient service applies to the first encounter that day.

There are no appropriate modifiers that can be added to the second E/M service.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q One of our doctors saw a new patient in labor and delivery, and then she was seen in our office for a more extensive exam and ultrasound on the same day, but by a different doctor. Normally I would bill both with a -59 modifier (Distinct procedural service) assigned to an evaluation-and-management (E/M) code, but I was recently told that the -59 modifier should not be assigned to an E/M code. How should I bill for these 2 separate encounters?

A You are correct. While the modifier -59 may be assigned when a distinct and separate service was provided on the same date of service, such as when there is a separate patient encounter, the services referred to in the CPT guidelines are medicine and procedural services, not E/M services. An article in the American Medical Association’s CPT Assistant (January 1999) clarified that the modifier -59 may not be appended to E/M services.

If the patient is seen for the same reason and the physicians are considered the same under the payer’s rules, bill only 1 E/M service for that day, but take into account all of the care the patient received during both encounters to select the right E/M service level. The ultrasound, of course, will be billed as well.

If the payer allows more than 1 encounter on the same day, the second encounter in the office must be reported as an established patient service, since a new patient service applies to the first encounter that day.

There are no appropriate modifiers that can be added to the second E/M service.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If I saw my patient in the Emergency Department (ED), can I bill one of the 99281–99285 codes for ED visits? Or are these codes only for providers who work for that hospital’s ED?

A No, these codes do not apply exclusively to services provided by the hospital’s ED employees.

You may use ED codes if you are the only one who provided services in that setting. But remember, the codes for ED services require that all 3 key components—history, examination, and medical decision-making—be documented. The “typical times” that are part of most E/M service definitions have not been established for these codes, so selecting the level based on counseling and/or coordination of care is not an option.

Lower relative values

Also keep in mind that the relative values assigned to lower level ED codes 99281 (ED visit; problem-focused history and exam with straightforward medical decision-making) and 99282 (ED visit; expanded problem-focused history and exam with low complexity of medical decision-making) are lower than their equivalent outpatient codes (99201, 99202, 99212, or 99213).

If the ED physician saw the patient first and is billing for that service, you need to bill the outpatient evaluation and management codes (99201–99215) or an outpatient consultation (9941–99245) if you documented a consultation in the record and if the patient is not being seen in the ED for a condition you are actively treating in your office setting.

This assumes you did not admit the patient to either observation status or as an inpatient. In that case, CPT rules would let you bill only the admission, but the code level selected would be based on all services you provided to that patient, on that day.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If I saw my patient in the Emergency Department (ED), can I bill one of the 99281–99285 codes for ED visits? Or are these codes only for providers who work for that hospital’s ED?

A No, these codes do not apply exclusively to services provided by the hospital’s ED employees.

You may use ED codes if you are the only one who provided services in that setting. But remember, the codes for ED services require that all 3 key components—history, examination, and medical decision-making—be documented. The “typical times” that are part of most E/M service definitions have not been established for these codes, so selecting the level based on counseling and/or coordination of care is not an option.

Lower relative values

Also keep in mind that the relative values assigned to lower level ED codes 99281 (ED visit; problem-focused history and exam with straightforward medical decision-making) and 99282 (ED visit; expanded problem-focused history and exam with low complexity of medical decision-making) are lower than their equivalent outpatient codes (99201, 99202, 99212, or 99213).

If the ED physician saw the patient first and is billing for that service, you need to bill the outpatient evaluation and management codes (99201–99215) or an outpatient consultation (9941–99245) if you documented a consultation in the record and if the patient is not being seen in the ED for a condition you are actively treating in your office setting.

This assumes you did not admit the patient to either observation status or as an inpatient. In that case, CPT rules would let you bill only the admission, but the code level selected would be based on all services you provided to that patient, on that day.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If I saw my patient in the Emergency Department (ED), can I bill one of the 99281–99285 codes for ED visits? Or are these codes only for providers who work for that hospital’s ED?

A No, these codes do not apply exclusively to services provided by the hospital’s ED employees.

You may use ED codes if you are the only one who provided services in that setting. But remember, the codes for ED services require that all 3 key components—history, examination, and medical decision-making—be documented. The “typical times” that are part of most E/M service definitions have not been established for these codes, so selecting the level based on counseling and/or coordination of care is not an option.

Lower relative values

Also keep in mind that the relative values assigned to lower level ED codes 99281 (ED visit; problem-focused history and exam with straightforward medical decision-making) and 99282 (ED visit; expanded problem-focused history and exam with low complexity of medical decision-making) are lower than their equivalent outpatient codes (99201, 99202, 99212, or 99213).

If the ED physician saw the patient first and is billing for that service, you need to bill the outpatient evaluation and management codes (99201–99215) or an outpatient consultation (9941–99245) if you documented a consultation in the record and if the patient is not being seen in the ED for a condition you are actively treating in your office setting.

This assumes you did not admit the patient to either observation status or as an inpatient. In that case, CPT rules would let you bill only the admission, but the code level selected would be based on all services you provided to that patient, on that day.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.