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.
- 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.
- 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.
- 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.
- 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.
- 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.
How can Quintessence’s expertise help?
Understanding the complexities of OB/GYN medical billing and coding is the first step to defeating it, and we understand that perfectly. In fact, our tools and services are designed to support our billers and coders to handle such complexities effortlessly.
Our coders are backed by our pride – the unfailing Machine Learning tool called Codessence. Codessence is built for the production environment and for teams that handle millions of codes regularly. The tool directly interfaces with EMR or hospital systems using HL7 or equivalent standards. It can be customized based on specific coding needs.
Codessence can move from encounters to claims in less than 24 hours and is proven to improve coder productivity by up to 50%. You may have a great medical billing and coding team handling OB/GYN bills. However, Codessence is like having another pair of eyes checking the codes, and errors are spotted before they turn into denials and revenue losses.
Reimburssence, another AI tool of ours, takes over once the coding part is done. This tool gives the AR team indispensable knowledge about the claims, helping them push claims to successful reimbursements. The tool uses a mix of analytics, intelligence, and insight to make the right decisions on claims. It nudges the team to take the right action at the right time and, over a period, improves touches to closures and the reimbursement rate.
You could be a hospital or an independent OB/GYN clinic. Outsourcing the medical billing and coding process is a smart way to avoid the complications of the process and get more time to focus on the patients and their wellbeing. RCM brands like Quintessence come with exceptional working experience with the US healthcare systems, and we keep ourselves aware of the latest changes in the medical billing industry. As a result, you can trust us to get the codes right, build the claims perfectly, and push them confidently towards reimbursements.
Do get in touch with us to get a demo of the tools and software we use and understand how they could change your RCM process for the better.