Getting paid for pregnancy complications

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.