Providing MFM Consultation in Labor & Delivery

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Authors: The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; Steve Rad, MD, FACOG, Chair; Katherine Kohari, MD, FACOG; David Smith, MBA, CPC; Trisha Malisch, CCS-P, CPC

Maternal-Fetal Medicine sub-specialists are often consulted to assist with the management of a patient in Labor & Delivery. How are these encounters coded appropriately?

Scenario 1

One of the generalist OB/GYN physicians in your community is managing the labor of a multiparous patient with a BMI of 35 and GA 39 weeks. They are having difficulty interpreting the fetal heart rate tracing and deciding on next steps for labor management.  The provider contacts you to review the strip and make recommendations.  You review the patient’s continuous FHR tracing, her history in brief, and promptly call back and recommend proceeding with cesarean delivery for an abnormal FHR. The patient is taken to the OR for delivery. There is no face-to-face encounter or ultrasound performed. You write a report with- consultation request and indication, your FHR interpretation, recommendation, and document communication with the requesting provider.

1. 59025
2. 59051
3. 59050
4. 59025 + Modifier 26
5. 59051 + Modifier 26
6. 59051 + Modifier 59
7. 76818
8. 99254
9. None of the above. I don't think this is billable / I have never billed for this. 

Answer: B (59051)

Scenario 2

One of the generalist OB/GYN physicians in your community is managing the labor of a nulliparous patient at 38 weeks GA. The patient develops elevated blood pressure, shortness of breath, and pulmonary edema during her labor and delivery admission, which is ongoing. The provider contacts you to review the chart, vitals, labs, FHR, and help with next steps for labor and delivery management. You are on call but remote from the medical center. You review all of the above. You call the requesting provider back, have a detailed discussion, and provide recommendations for the management of pre-eclampsia with severe features at term. You document your evaluation and management recommendations in the patient’s chart in a written report. Your documentation reflects verbal request and reason for the consultation. There is not a separate report for the FHR review and interpretation. You spent a total of 40 minutes in chart review, documentation, and communication with the requesting provider, with > 50% spent in verbal discussion with the requesting provider. You don’t see the patient in the hospital, however, the generalist OB/GYN did tell their patient that you are being consulted and will be billing for this service; the patient completes consent forms requested by your office.

1. 99254
2. 99051
3. 99223
4. 99232
5. 99446
6. 99449
7. 99451
8. None of the above. I don’t think this is billable / I have never billed for this.

Answer: F (99459)

Scenario 3

One of the generalist OB/GYN physicians in your community is managing the labor of a nulliparous patient at 39 weeks GA. The patient has an underlying maternal congenital heart defect. She requires telemetry monitoring and careful management of IVF. The OB/GYN physician is asking for help with the management of this patient in labor both in the setting of her cardiac defect as well as a separate request to review the FHR tracing for her. You are remote from the medical center. You do a full chart review. You also review the continuous FHR tracing and note a category 2 tracing. You do a face-to-face virtual inpatient consultation with the patient. You document your visit, including request/reason for consultation, record review, exam, and management recommendations for this patient with complex maternal congenital heart defect in labor. You separately review the FHR as well. You generate a separate report for the FHR review with your interpretation and recommendation; your recommendation is to institute resuscitative measures, and if unresolved in 30 minutes, to proceed with cesarean delivery. You convey your recommendations to the requesting provider, assist with coordination of care, and ensure the provider will be monitoring the FHR closely over the next 30 minutes and properly managing the cardiac issues. The patient is counseled, understands and agrees with the assessment and plan of care. You spend 80 minutes on the counseling and coordination of care of this complex patient requiring high-level MDM (separate from the FHR consultation). Your coding will appropriately reflect that the visit was done virtual/telemedicine. Your payer does not recognize consultation codes.

1. 99255 + modifier 25 and 59051
2. 99255 + modifier 25 and 59025
3. 99223 + modifier 25 and 59051
4. 99223 + modifier 25 and 59025
5. 99223
6. 99221
7. 99449
8. 99232
9. 99254
10. None of the above. I don’t think this is billable / I have never billed for this.

Answer: C (99223 + Modifier 25 and 59051)

Telehealth modifier 95 or GT (depending on payer) would be appended to the E/M code as well. Place of service (POS) 02 would be used for a patient in the facility setting (not at home). In this case the payer does not recognize consult codes per the vignette, so choice C is appropriate. If the payer did recognize consult codes, then choice A would be correct choice as well.

Explanation

59025 is for the interpretation for a Non-Stress Test, instead 59051 “Fetal monitoring during labor by consulting physician (i.e., non-attending physician) with written report; interpretation only”, would be the correct code for a patient in labor with continuous fetal heart monitoring requiring interpretation and guidance on intervention and such as delivery by cesarean section. This code includes physician interpretation of the FHR, conveying the interpretation to the requesting provider, and a written final report in the chart. This is an inpatient code and does not require modifier 26. This code includes when consulting physician interprets a fetal monitoring strip and gives advise to the attending physician about any needed changes in the management of the labor. (You would bill a separate E/M if it were performed on the same date of service ONLY if for a different indication; modifier 25 would need to be appended to the E/M code).

If an interprofessional consultation is performed with verbal communication and majority of time >50% is spent in internet or verbal discussion with requesting provider, then the interprofessional codes 99446 – 99449 would be used. CPT 99449 is Interprofessional telephone/Internet/electronic health assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review. As in the scenario above, both verbal and written report to the patient’s treating/requesting physician is required. A written or verbal request should be documented in the patient’s medical record, including reason for the consultation. Best practice is to inform the patient that the consult is being requested/performed and that they will be billed for the services (might be responsible for patient share such as deductible or copay); best practice is also to obtain your practice’s standard patient forms and consent forms. This code group can be used for new or established patients.

Code 99451 is used for: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified healthcare professional, 5 or more minutes of medical consultative time. Majority of time >50% is spent in data review. No verbal communication is needed. Written report is required.

The inpatient consultation E/M codes (99252-99255) should be used if consultation criteria are met, and you physically or virtually (telemedicine) see the patient face-to-face and provide consultation. The consultative code may be switched to initial patient encounter codes (99221-99223) should the payer not recognize consultative codes. You can also code based on time rather than MDM.

Please see the SMFM Coding Committee White Papers and Tips as related to Interprofessional Codes, Inpatient E/M coding, and Telemedicine at our website below for further information.

Please submit any questions you may have to the SMFM Coding Committee Ask a Coding Question website (https://www.smfm.org/coding). Additional information and resources are also available on our coding website. Thank you very much.