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Common Mistakes on Coding and Billing Antepartum Care for OB-GYN Specialty - E/M versus Antepartum Codes?

I was recently approached by an OB-GYN practice in New Jersey to look over at their billing and coding based on their EOBs, Superbills and Medical Records. Only to find out (on my first day!) - they have problems.

One of the many things I have seen are, billing and coding for E/M codes when it should have been an antepartum care service (59425-Per CPT is 4-6 prenatal visits and 59426 Per CPT is 7+ prenatal visits.

With this problem, it is possible the provider were not actually maximixing their reimbursement.

Why is that? well, obviously if you use 4 E/M Codes for a total of 4 prenatal visits, for instance, you will be approximately be reimbursed at $54.00 at 99213 level, multiply that into 4 visits -- that's a total of $216.00! not unless you do a high level of E/M (based on medical necessity though!). And realistically, you don't follow the proper way to code and bill for antepartum care! (per CPT).

If the patient came to the office as a new patient or have initially established the pregnancy, you can bill that first visit as a separate E/M code for pregnancy confirmation. If the patient came in for another 3 prenatal visits and transferred to another physician, you can bill 3 of E/M codes. But if the patient came in for additional 4 visits, then code and bill for antepartum code per CPT 4-6 visits code 59425.

Now, let's go back to maximizing your reimbursement. If you bill for CPT 59425, most of the insurance companies approximately allows at least $425 for this code. Compare it at $216 for 4 E/M Codes!

Realistically too, most of the patients stays with their physician until they deliver the baby. Then, that time, you bill for the global package which includes antepartum, delivery and post partum.

Always consult your CPT and ICD books as a reference. Get yourself knowledgeable with CCI edits, policies and guidelines with your contracted insurance companies. Know your contracted rates and their policies.

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