Watch out for these Ob-gyn coding pitfalls that could threaten your bottom-line in 2019.
You’ve figured out all the latest ICD-10 and CPT® updates impacting your ob-gyn practice, so your work is done—right? Certainly not, as ob-gyn coding practices will not be easy this year!
In this post, we focus on some challenging, revenue-threatening areas you’ll need to tread in 2019 and provide practical steps to help you keep your ob-gyn claims on track.
Watch Out! Modifier 57 High on RAC Alert This Year!
Modifier 57 (Decision for Surgery) may seem pretty straightforward to use, but many practices are appending it incorrectly — leading to its recent addition to the RACs’ list of open issues! Can your ob-gyn practice pull through RAC scrutiny this year?
A sure way to overcome modifier 57 claims issues is to review background on proper use of the modifier. You should use modifier 57 when an E/M service leads to the physician’s initial decision to perform the surgery.
Tip: Add modifier 57 to the E/M code to indicate that the E/M service resulted in the decision to perform a surgery with a 90-day global period on the same day. Always be careful to add modifier 57 to the E/M code, and not the surgical procedure code.
Add Additional Character for O86.0- Codes to Avoid Denials
A plethora of new codes became available for obstetrical surgical wound infections on Oct. 1, 2018. Along with these changes, you can also find individual codes for deep incision sites, incisional site, sepsis, organ and space site, and more. So, ob-gyn coders will need to be extra careful while reporting new ICD-10-CM codes under O86.0-.
Prior to Oct. 1, 2018, O86.0 was a complete, reportable ICD-10 code for ob-gyn. In 2019, you need an additional character that provides more detail about the wound site. Remember, if you forget the additional character for O86.0-, your payer will not accept the code, and you’ll receive a denial.
Hone Your Modifier 59 Skills to Prevent Denials
Note that carriers are still scrutinizing submissions for separate and distinct services due to OIG’s high error rates. And if you’re not careful about how you report modifier 59 (Distinct procedural service) claims, your ob-gyn practice could be end up in hot water!
However, you can avoid paybacks by following these two tips:
First determine separate regions – Check a sample of your modifier 59 submissions and see whether the claims properly represent a distinct procedure. Note that 15 percent of the OIG’s audited claims with this modifier had procedures that were not separate, as they were performed at the same session, same anatomical site, and through the same incision. So, the key is to ensure the physician is working in a separate body area before appending modifier 59.
Secondly, use modifier 59 on the secondary code. CCI publishes a list of comprehensive/ component edits consisting of two codes that can’t be performed together based on the code definitions or anatomic considerations.
Follow These CCI 25.0 Edits to Beat Ob-Gyn Claims Denials
Many practices are witnessing a spike in denials due to the latest round of CCI 25.0 edits. To ensure your ob-gyn practice doesn’t suffer the same fate, adhere to the latest CCI edits relating to active surgical, ultrasound, and E/M edits.
The first quarter edits bundle new FNA biopsy codes — 10005, 10007, 10009 and 10011 as column 2 codes to CPT codes for ob-gyn. CCI also bundles new skin biopsy codes (11102-+11107) into the vulvar biopsy codes 56605-+56606. The latest round of edits also puts the spotlight on these 2019 ultrasound codes: 76978, +76979, 76981, 76982, and +76983.
Avoid Making This $139 Mistake in Your Ob-Gyn Practice
If you are not sure whether to report a vulvectomy code or a vulvar lesion excision code, focus on these three aspects in the report: The type of lesion, lesion size, and the layer closure. If the lesion is not discrete and involves large areas of tissue, the ob-gyn will perform a vulvectomy. However, for lesions that are discrete and localized, you will look at the “Integumentary System” chapter of your CPT® coding book (instead of the “Female Genital System” chapter).
Check your RVUs — all vulvectomies have more RVUs than lesion excisions because vulvectomies involve much more work. For example, the code 56620 pays $559, while the most expensive of malignant lesion excision codes (11620-11626) have a $420 non-facility allowable. And that’s a difference of $139.
Perfect Your Global Maternal Care Packages’ Start Date
In the coming months, if your ob-gyn discovers that a patient is pregnant during her annual visit, how will you report this? The answer depends on the method your ob-gyn used — however the challenge does not end there, as you have to decide what clinical diagnosis to use. The key is that in the majority of cases, you should not start counting antepartum visits for the global maternity codes — 59400, 59510, 59610, 59618 — until the next full visit.
As you are likely aware, annual visits often lead to confusion when it comes to establishing a patient’s pregnancy. Do you know how to tackle these cases? The key is to select from a range of different E/M codes according to three scenarios. Need insight on the three scenarios?
Don’t Let Your Hard-Earned Ob-Gyn Pay Fall Through the Cracks
Get in-depth help to tackle these cases, and more, in Ob-Gyn Coding Alert. TCI’s certified editors will help you triumph over the revenue-risking issues that threaten your claims and compliance success in 2019 — and beyond. From the latest ob-gyn coding guidelines to money-in-the-bank answers for your toughest ob-gyn coding questions, this indispensable resource has you covered.