Submitting claims for inpatient E/M visits with multiple providers involved
In many cases, MFM providers may only be involved in the management of a pregnant patient but do not perform the actual delivery. Typically, the delivery codes that are used to submit a claim after delivery include complete global services (Admission, delivery management, postpartum care, and discharge). When this occurs, unbundling is required before claims submission which can be challenging when the MFM specialist is only providing portions of the treatment together with other providers.
Let's take a look at some scenarios and the appropriate way to report them:
1. MFM admits a patient for labor induction with severe hypertension at 36 wks. The hospitalist performs the delivery after 24 hours of being admitted. Is the admission E/M a billable service for the MFM?
If a patient is admitted by the MFM with the intent for delivery, then the admission E/M is not usually billable on its own unless the patient is later discharged without being delivered. If the patient indeed delivers, then the admission and delivery are part of the global delivery CPT code and the admission would not be a billable service for the MFM. The MFM should negotiate with the delivering provider for the admission component. Otherwise, if the patient was seen in the MFM’s office before the admission, then that E/M visit may be billable by the MFM.
2. The MFM provider admits the patient with no intention to deliver but the patient eventually delivers during that admission. Is the admission E/M a billable service?
Examples include admissions for PROM or preterm labor that are not meant to deliver (i.e. for expectant management or tocolysis). The group that admitted and rounded on that patient is able to bill and get reimbursed for those services since they are outside the scope of routine delivery care of a patient. If the patient is admitted and the decision to deliver happens on the same day, e.g. few hours later, then modifier "57" should be appended to the admission E/M code.
3. The hospitalist manages labor and delivery and bills for those services while the MFM provider sees the patient to manage the intrapartum hypertension, etc. Are the MFM visits billable?
Yes, medical problems complicating labor and delivery management may require additional resources and should be identified by using subsequent hospital visits with modifier "24", regardless if they are your own patient or not.