Obstetrics and Gynecology (OB/GYN) is a very busy division of any healthcare organization. This branch deals with childcare, pregnancy, and female health issues. It is common acceptance that OB/GYN is one of the most challenging branches for medical billing and coding experts. OB/GYN practitioners perform and recommend various tests and procedures for pre and postpartum women, and suggest different screenings for women in different age groups. As a result, OB/GYN billing and coding get complicated.

All OB/GYN teams, starting from those in massive hospitals to smaller clinics and private practice firms, get equally flabbergasted with the Medical billing and coding guidelines. Spending time getting the backend processes right means that the team doesn’t have the time to focus on their practice. Keeping updated with the ever-changing medical billing laws and standards and going back and forth with submissions and re-submissions of claims is something these practices best avoid.

Here are some of the challenges of coding and billing OB/GYN procedures.

1. Separating billable services – Because of the large number of tests and procedures involved in patient care, the Medical billers and coders need to identify separately billable services and not bundle them together with pre or postpartum care. Consider a pregnant woman. She would need a variety of services from the first day of pregnancy until after delivery. Also, some of these services may not be pregnancy-related. In that case, these can and should be billed separately outside the global package. This ensures that the provider is reimbursed fairly.
2. Missing out the right information – Many times, claims are rejected because of a lack of specific information required for reimbursement. Physician documentation may miss out on relevant info needed to bill the claim appropriately. This is when tools like the Quintessence’s Doctor’s Portal come to help. With this tool, you can get the required information directly from the provider. Most of the time the doctors miss mentioning the specificity in diagnosis and with the advent of ICD 10, it is now a known fact that unspecified diagnosis will be rejected by the payer with the claim getting denied.
3. Understanding the necessity of a procedure – E.g. Medical necessity is one of the major reasons for claim denial. Coders must review the document thoroughly and understand the cause of the visit. If there is any mismatch in the procedure performed and the purpose of the visit, claims will be denied. A perfect example of such a mismatch is when the patient visits the physician as part of their annual wellness care. The code for this is Z01.419 (Encounter for gynecological examination (general, routine) without abnormal findings) or Z01.411 (Encounter for gynecological examination (general, routine) with abnormal findings) which is to be used as the primary code, if the coder codes any other normal visit code the claim will be denied.
4. Understanding the delivery codes – There are so many codes allotted depending on the service provided, the assistance used, and the type of postpartum care offered. The coders need to understand the type of service provided to code right. Consider this example. A woman is provided antepartum, delivery (vaginal) as well as postpartum services by the same physician. The appropriate is CPT 59400 (Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care). However, if the physician had only provided the vaginal delivery service, the CPT code is 59409 (Vaginal delivery only (with or without episiotomy and/or forceps). Understanding the different code sets makes all the difference in getting the maximum reimbursement.
5. ICD 10 guidelines for pregnancy, childbirth, and the puerperium – ICD Guidelines carry equal weightage as that of the CPT guidelines. The very fact that the ‘O’ codes should be prioritized even above life-threatening conditions like AIDS and should be listed as the first-listed diagnosis proves the importance given to this specialty. Coders should read and understand the medical record and identify the complication so documented and provide the appropriate code. Hence, attention to detail is very vital for getting claims paid in this specialty.