Payment for services during miscarriage
<huc>Q</huc> At 19 weeks’ gestation, our patient presented to the emergency room leaking amniotic fluid. The umbilical cord was protruding through the vagina and the fetus was in breech presentation. She was not in active labor. Ultrasound showed no amniotic fluid around the fetus and no fetal heart rate. We induced labor, which lasted 16 hours. How can we bill?
<huc>A</huc> If this labor was induced with misoprostol or another cervical dilator, the correct code is 59855 (induced abortion, by one or more vaginal suppositories [eg, prostaglandin] with or without cervical dilation [eg, laminaria], including hospital admission and visits, delivery of fetus and secundines). It is not appropriate to bill for delivery unless the fetus is older than 20 weeks 0 days gestation or is born alive, which was not the case here.
Induction with IV oxytocin would be classified as medical management of an abortion. Under CPT rules and ACOG guidelines, you would bill only for the evaluation and management (E/M) services. However, this means you would be billing for the hospital admission, subsequent care, and, prior to delivery, prolonged physician services. In this case you would report the hospital prolonged care codes that account for the actual time you spent with the patient managing her labor, as long as that time exceeds by 30 minutes the typical time of the E/M code you reported (TABLE).
For instance, if she is admitted at 10 PM on day 1 and delivers on day 2 at 2 PM, with your having documented that you spent a total of 2 hours at the patient’s bedside on day 1 and 8 hours at the patient’s bedside on day 2, you could bill as follows:
Day 1: Hospital admission (eg, 99222, requiring comprehensive history and exam and moderate medical decision-making with a typical time of 50 minutes)
Prolonged services on day 1: 120 minutes total –50 minutes=70 minutes of prolonged service. Bill code 99356 (first 60 minutes), but no additional code for the last 10 minutes of prolonged service.
Day 2: Subsequent hospital care (eg, 99232 requiring an expanded problem, focused history or exam with moderate complexity of medical decision-making with a typical time of 25 minutes).
Prolonged services for 8 hours on day 2: 480 minutes total –25 minutes=455 minutes of prolonged service; bill code 99356 (first 60 minutes), and 99357 with a quantity of 13 for the remaining 395 minutes.
You have to do the math: Coding prolonged physician services
TOTAL TIME W/PATIENT
BILLABLE PROLONGED SERVICE
PROLONGED SERVICES WITH CODES REPORTED
Day 1 120 minutes
99222 (50 minutes)
120 min –50 min=70 minutes
99356 for first 60 minutes, but no extra codes for last 10 minutes
Day 2 480 minutes
99232 (25 minutes)
480 min –25 min=455 minutes
99356 for first 60 minutes; 455 min –60 minutes=395 minutes 99357×13 for remaining time (13 times for each 30-minute increment)