When your ob-gyn delivers one baby vaginally and the other by cesarean, you should report two codes, but you'll only report one code if your ob-gyn delivers both babies by cesarean. Find out which codes to report by reading these scenarios and discover the coding solutions.
Ob-Gyn Delivers Both Twins Vaginally
If your patient is having twins, most ob-gyns first attempt a vaginal delivery as long as the physician hasn't identified any complications.
Solution: When your ob-gyn delivers both babies vaginally, you should report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; multiple procedures) for the second.
Your diagnoses will be 651.01 (Twin pregnancy; delivered, with or without mention of antepartum condition) and V27.2 (Twins, both liveborn), says Peggy Stilley, CPC, ACS-OB, OGS, clinic manager for Oklahoma University Physicians in Tulsa.
Be wary of modifiers. "Some payers want you to use modifier 51, while others prefer you to use modifier 59 (Distinct procedural service)," says Jenny Baker, CPC, professional services coder of Women's Health at Oregon Health and Sciences University in Portland. So be sure to check with your payers to determine which modifier you should use.
Choose 2 Codes for Vaginal, Then Cesarean
If the physician delivers the first baby vaginally but the second by cesarean, assuming he provided global care, you should choose two codes.
Solution: You should report 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care) for the second baby and 59409-51 for the first. "You'll bill the cesarean first because of the higher RVUs [relative value units]," Stilley says.
The diagnoses for the vaginal birth will include 651.01 and V27.2 as diagnoses, Baker says.
For the second twin born by cesarean, use additional ICD-9 codes to explain why the ob-gyn had to perform the c-section--for example, malpresentation (652.6x, Multiple gestation with malpresentation of one fetus or more)--and the outcome (such as V27.2), experts say.
Hint: You should always be sure that you're billing the global code for the more extensive procedure, Baker says. For example, the work relative value unit for 59400 is 23.03, and the RVU for 59510 is 26.18--a difference of about $120.
Use 1 Code if Both Cesarean
Rule of thumb: If the ob-gyn delivers both babies by c-section, you should only bill that once, Baker says.
Solution: When the doctor delivers all of the babies--whether twins, triplets, or more--by cesarean, you should submit 59510-22.
Report 59510 with modifier 22 (Unusual procedural services) appended, Stilley says. Because the ob-gyn made only one incision, he performed only one cesarean, but the modifier shows that the ob-gyn performed a significantly more difficult delivery due to the presence of multiple babies. Be sure to include a letter with the claim that outlines the additional work that the ob-gyn performed to give the carrier a clear picture of why you're asking for additional reimbursement.
Editor's note: For more information on how best to use modifier 22, see "Mind These Modifier 22 Do's and Don'ts".
Finally, as far as the diagnoses go, "include the reason for the cesarean, 651.01, and V27.2," Stilley adds.
What if They Come on Different Days?
Occasionally, multiple-gestation babies will be born on different days. For example, a patient is at 38 weeks gestation and carrying twins in two sacs. One membrane ruptures, and the ob-gyn delivers the baby vaginally. Two days later, the second ruptures, and the second baby delivers vaginally as well.
Solution: Here, you should report the first baby as a delivery only (59409) on that date of service. For the second, you should bill the global code (59400), assuming the physician provided prenatal care, on that date of service. The reason not to bill the global first is that you are still offering prenatal care due to the retained twin.
You will have to attach a letter explaining the situation to the insurance company. ICD-9 will be important to the payment, so make sure you send as much documentation as you can find, Baker says. Be sure to use the outcome codes (for example, V27.2).
Good advice: If you receive a denial for the second delivery even though you coded it correctly, be sure to appeal, Baker adds. "Usually you'll be paid after the appeal."