OB Hospitalist-‐ Coding Comments to ACOG Committee on Coding and Nomenclature
1) L&D Triage. Many OB Hospitalist programs have the OB Hospitalist do the full EMTALA examination or the exam after initial nurse triage. Some of these patients are in labor and are admitted as such. Others have various medical conditions some of which are partially obstetric. There are many questions on how to bill for these things to allow appropriate
reimbursement.
a. Eventual L&D admissions
i. Admitted to private OB service physician
1. If a patient shows up to the ED and an evaluation is made by an ED physician and then transferred to L&D for labor. Can the ED physician bill for the visit? If a patient presents to L&D and an OB Hospitalist does a workup can the Hospitalist bill for the evaluation? If the ED physician can bill it would follow that the OB
Hospitalist could be reimbursed for an evaluation.
The ED physician cannot bill for that visit is my understanding. Hence the reason every pregnant woman is sent to L&D triage for evaluation. The L&D hospitalist can bill if she goes home. Then it is billed as an
outpatient visit (and since the hospitalist is covering, that is an
established patient) unless the hospital has the L&D triage certified as an ER (most hospitals don’t because it takes a lot of extra manpower and equipment to be a certified ER).
ii. Admitted to OB Hospitalist service. Can the OB Hospitalist bill for the admission and subsequent hospital care? When would this be included in global OB care vs. admission, hospital E&M and then delivery?
If they are covering for a physician who performs deliveries, then arrangements should be made with the practice for reimbursement of services. If they are covering for a practice that does not do deliveries (we have a few here in Indy who just do antenatal care and the 6 week visit) then they bill for the delivery and inpatient postpartum care code (59410 and 59515 for vaginal and C/S).
iii. The workup is done at times for patients that present in early labor. One laborist spends 45 minutes working up these patients. She would like to code and bill for this separate from the global charge, which is charged by the patient’s primary physician.
She can bill this as an outpatient E&M plus NST unless the patient is admitted. If admitted, should work out a deal with the covering physician.
b. OB Hospitalist manages the total outpatient episode of care and the patient is discharged without admission.
i. False labor, etc. Can this be billed as an E&M code?
ii. Asthma attack requiring treatment and change in medications, etc. Can this be billed as an E&M code?
If not admitted, outpatient E&M. The ICD-‐9 codes just help to speed reimbursement along.
c. Transfer to ED
i. Patient worked up in L&D with eventual transfer to the ED for workup of non-‐OB condition. Can this be billed separately from the ED physician? Which codes can be used?
1. Coexisting OB-‐non OB issue 2. OB issue ruled out
I would think it would be an outpatient code again—just like in the office.
d. Transfer to another service. Which codes should be used? i. Example: patient transferred to surgery service for an
appendectomy.
See above.
e. Transfer to another unit but managed by the OB hospitalist with consult to another service.
i. Example: Surgery service plans to do an appendectomy but wants the OB hospitalist to manage the patient’s care
If admitted to the hospitalist, the hospitalist bills the appropriate inpatient admission code, consults the general surgery service and continues inpatient care. Care may be denied because the appy carries a global period and the hospitalist needs to use the ICD-‐9 codes that will say the care was for pregnancy issues—likely the V codes since no pregnancy issue actually exists. However, most surgeons would admit and then consult the hospitalist and then the hospitalist bills the initial consult code and then subsequent hospital care codes.
2) L&D Procedures a. Ultrasounds
i. Some programs allow nursing to do some sonograms. Others only allow radiology to provide these services. Most allow the
OB hospitalist to do some L&D sonograms. The sonograms are to determine fetal position, placenta localization, AFI,
biophysical profile, growth scans, etc. How does the Hospitalist bill in each of these scenarios?
The hospitalist can bill for the professional component (hospital owned equipment I’m assuming), but must prepare a written report and documentation AND the hospital radiologist cannot bill for the
professional component. This should be arranged through the hospital. No value can be given for a nurse US with a nurse interpretation of images. Thus the physician must review all the images and prepare the report. More than most hospitalists want to cover since they would now be liable for any misinformation or missed diagnoses.
b. Monitor FHR
i. Read NST-‐ the Hospitalist would charge for the interpretation fee.
Unless the patient is in labor—then it is included. Only bill this if the patient is an antepartum care (such as PPROM, PTL, etc.) or evaluating for labor. If actually in labor, considered part of the care.
ii. Following a patient in labor and responding to nursing or physician requests to evaluate a Category 2 or 3 tracing. There does not seem to be a way to bill for these services that can take from a few seconds to several hours of OB Hospitalist presence.
Correct. All included in the global payment for labor.
c. Amniocentesis, version, etc.
i. Most OB hospitalists bill for these procedures but there is some concern that the services won’t be recognized if the patient is admitted when the procedure is done and the procedure is considered under global care, or that the procedure is
performed by a physician with similar training as the attending so the procedure cannot be billed separately. This concern is expressed below in 3).
I haven’t ever heard of this happening. Is this theory or reality? 3) Consultations
a. Family practice physicians with OB privileges, and nurse midwives. i. Most OB Hospitalists feel they can bill for services and
consultations when a Family Practice physician requests it. Some insurance companies may deny the OB Hospitalist’s services in this situation.
Should be able to bill for it and if they are denied, should refile and petition state insurance commissioner if it is habitual. OB has higher level of expertise.
b. OB Physicians (Same level of care).
i. Most OB Hospitalists feel that they cannot bill for services when asked to see a patient by another OB. This would be for services that the OB may not provide but would be considered in the scope of practice. An example would be management of an eclamptic seizure.
Correct. Included in payment for labor.
c. Procedures done per request of nursing or OB Hospitalist acts in an emergency setting without an official consult being made prior to action. How are these coded and how can the OB Hospitalist bill for these emergency services.
No procedures can be done at the request of nursing. Ever. If an emergency occurs and the admitting physician wants to ask the hospitalist to cover (e.g., emergency C/S), then the hospitalist can bill delivery only codes or the OB can bill global and give part to the hospitalist.
4) Global Billing
a. Most insurance companies will pay for global OB and consider almost everything from admission until postpartum discharge as part of the global fee. When the OB Hospitalist provides some or all of the care there are very few options for billing for services or division of services.
i. One physician stated that if she does the delivery BCBS pays $1000 to the patient’s physician for prenatal care. The company pays the hospitalist $1000 for the delivery. If the private physician bills for the prenatal care and delivery then the company pays $3000.
This is the classic example of working with the practices in town to negotiate a fair fee for service and then the practice pays the physician for coverage. I’m not sure what Stark laws exist for kickbacks to the hospital—that’s for legal. If a physician covers for another physician from another practice then the practices work out a fair reimbursement.
ii. Many physicians feel that antenatal care is not reimbursed appropriately and that “easy” labor and deliveries make up partially for this. The physicians don’t want to give up the
delivery fee, or divide it with other providers who care for the patient during labor.
A great topic for discussion at the local hospital OB committee.
5) Reciprocal Billing
a. Many OB Hospitalist programs get around many of the billing issues by doing reciprocal billing. There are two ways this is done. In both for the attending physician does global OB billing.
i. Fee per patient
1. A fee is billed to the attending physician by the OB Hospitalist to manage:
a. Labor (ex. $350)
b. Manage Labor, Delivery, Hospitalized post partum (ex. $500)
2. Fee billed to the attending physician per unit of coverage (usually monthly).
a. Busy physicians are billed for example $1000 per month.
b. Physician with few deliveries are billed for example $100 per month.
b. None of the programs sharing information said they made money from reciprocal billing. They all depended on covering the cost overrun of the program with using other
hospital funds.
6) Differences between OB and OB Hospitalist
a. The OB is not expected to stay in house for the entire labor. The exception would be for a TOLAC. Even then the reimbursement is not considered work appropriate for the time. If the labor is monitored for any labor should the laborist be able to bill for in house monitoring of the labor? The laborist is expected to be able to respond within seconds where the OB is expected to respond in 20-‐30 minutes.
I think this is included in the payment for labor and delivery. If the
hospital wants an OB doctor onsite, 24/7, the hospital should be prepared to pay for that.
b. If the OB Hospitalist develops skills criteria that are above the usual skills expected of the general OB should the hospitalist be able to bill for the services. An example is management of an eclamptic seizure or DIC. These are in the scope of practice for a general OB but are often managed at least in consultation by a different specialist.
Unfortunately, there is no hospitalist fellowship like there is an ICU fellowship. Thus, there is no difference between this and the generalist
who becomes really good at laparoscopy—she gets paid the same as everyone else for the same service.
7) Differences between the Medical Hospitalist and the OB/Gyn Hospitalist. a. The medical hospitalist does not do an ED evaluation. The medicine
patient is admitted through the ED or a private physician. There is almost never a direct admission to the medicine hospitalist service without a prior workup.
b. The OB Hospitalist is often called upon to evaluate patients without access to prior medical records or a recent examination based on the admission complaint.
c. The OB Hospitalist often provides her services during an episode of global billing. The medical hospitalist services are separate from global billing.
d. The OB/Gyn Hospitalist does a lot of outpatient care as well as
outpatient care with change to inpatient care during the same episode of care. The medical hospitalist almost always only takes care of hospitalized patients.
e. The Ob/Gyn Hospitalist needs a way to bill for these services. There is no analogous service for medical hospitalists.
Submitted for the Society of OB/Gyn Hospitalists 11/26/11
