OB Billing: Package v. Visit

Billing OB services in the FQHC environment can be tricky as payers choose their payment methodology.

Objectives for this Session

• Explain OB Package Billing• Discuss timing of posting the package• Explain per visit OB Billing• Partial Package billing and when its

appropriate• Best Practices• Forms and Tools for OB Services

OB Package Billing

• Billing OB services in a package is the more traditional way of billing.

• Private practices OB clinics use this method (almost) exclusively.

• FQHC payment methodology creates options for CHCs.

How do I know?

• Private Insurances usually pay package• Medicare ONLY pays package• Medicaid varies state to state

If you are in a state with high managed care for Medicaid recipients, carriers may follow different models

Changes in patient eligibility may mean changes in methodology

• Patients can be billed package or per visit as long as you have FQHC status.

CHC Research• Research

oWho are your largest OB payers?oWhat method does each payer require?o Be prepared for payers to “misuse” CPT

codes! Understand payers’ coding.o Payer rules will override CPT coding

rules!

Payer QuestionnairePayer Name ___________________________ Date of Call ____________ Emp Calling ________

Ins # Called for Info _______________________

Note: The absolute best bet you have in getting the information that you need IN WRITING is to get the website of the payer and get to the most current information that you can.

*Remember to ask several times during the call if they can fax that information to you, they will get the message, you want it in writing.

Do you have a website with current Obstetrical (OB) billing information that I can read? What is the site? __________________________________________________________________________

Do you reimburse for a pregnancy package or per visit? Pkg Visit If Per Package, Proceed directly below: If Per Visit, hop down to Orange area. What is included in the package? They will list, write fast: Could they fax it to you???

What is not included? At this point go through this list: Ultrasounds Y N How many will they cover?

Blood Glucose for diabetes Y N

Triple Test for Down ’s syndrome and other genetic problems Y N

How many days in the hospital after delivery are included in the package? __________

Do you want the dates of service for the OB visits listed on the claim? Y N

If yes, what box on the CMS 1500 form are those expected to be in? _______

Per Visit Questions: Is there something they can fax to you?

Is there a limit on the number of OB office visits covered? Y N

If yes, how many? _______________

Are there any services that they will not pay for a pregnant woman?

CHC Decisions

• Decisionso If your payers require a mix of

methodologies, how will you bill your self pay and sliding fee patient populations?

oWill your SFS differ for OB patients?o Later we’ll get to the decision of adding

the package to your AR earlier or later in the process.

Pricing & Sliding OBPricing:• Delivery is 60% of the work in a package• Price using usual method• Test with other OB clinics in your area• Partial package w/o del=40% of pkg

Sliding:• Slide the same as other medical services?• Slide a max of 50%• Set a nominal fee for the package

What is included in the package?

• Monthly visits to week 32• Bi-weekly visits from weeks 32 to 38• Weekly visits from weeks 38 to delivery• Delivery• Discharge from hospital• Post partum visits

– Two for vaginal delivery – Three for cesarean section delivery

What is NOT included in the package?

• Pregnancy test• Lab work: hcg quants, glucose, triple

test, genetic testing, Rh injection• Ultrasounds• Office visits for illness or injury not

related to pregnancy• Hospital visits for illness, injury,

threatened or premature labor, or additional days stayed

Billing OB Packages• Package cannot be billed until delivery – when

majority of services are complete• Enter a dummy code for initial billing of the

packageo OBSTD – for vaginal deliveryo OBCSD – for planned cesarean delivery

• No charge visits for OV • Bill charges for services not in package• Decision:

o Post package at beginning of services, AR ages throughout

o Post package at delivery, AR ages from delivery

Pros and Cons of OB Package Posting at Start of Services

Pros

• Patients can pay toward their package or portion

• Easy to track your OB business

• Better patient compliance with visits

Cons

• Inflates AR for services in the future

• Mistaken filing prior to delivery

• Adjustments will be necessary if delivery method changes from what is initially billed

Pros and Cons of OB Package Posting at Delivery

Pros

• Posted when majority of charges are due/delivered

• No adjustments for different delivery method

Cons

• Patients often have ‘sticker shock’

• No collections from patients throughout service delivery

OB per Visit Billing

• Billing per visit is an option because of the FQHC payment methodology

• Just as it sounds, you bill for each service provided

• Some payers require this type of billing

• Patients billed this method tend to attend fewer OB visits

Adding OB ARBilling Method Pos Pg Test OB Intake OB Visit …OB Visit …OB Visit …OB Visit Delivery PP 3 days PP 10 days

Bill

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Bill

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When a Partial Package is Appropriate

• If your clinic doesn’t have doctors doing delivery at a hospital

• If the patient terminates, miscarries or is lost to follow up during care

• If you do prenatal and post partum services, don’t forget to bill for the post partum care.

Adjusting OB Billing• Patient is self pay through OB care

and gets e-med for delivery• Patient is presumptive Medicaid

eligibility at start of care• Patient gets or loses insurance during

pregnancy• Be familiar with billing/coding: ie.

laceration repair, placenta delivery only, precipitous nurse delivery, etc

Codes to Consider Building

• 99212OB, 99212OB NC, 99213OB, 99213OBNC

• 99212PP, 99212PPNC, 99213PP, 99213PPNC

• 59409, 59409NC• 59514, 59514NC

• OBSTD, OBCSD

• For billing charge and no charge OB visits

• For billing charge and no charge Post Partum visits

• Both vag and c/s charge and no charge del

• Dummy code for package pmts

Additional Codes & Recap

• Vaginal Delivery Package 59400• C/S Delivery Package 59510• 1-3 visits, post each visit (E/M)• 4-6 visits, post 59425• 7 or more visits, post 59426

These slides are in no way an exhaustive list of codes used for OB services. Please consult current CPT resources for additional codes relating to these services and other types of delivery.

Best Practices

• Educate patients – create materials and present to every OB patient

• Patient payment agreements on OB care – include allowing patients to pay toward OB directly (as opposed to oldest due)

• Build a case for delivery – UDS information

More Best Practices • Staff (OB Specialist) follow OB patient

from positive pregnancy test through outcome of delivery, PP care– Education - explain services, explain

costs– Accountability – is patient making visits,

payments, need additional care– Follow up – outcome of delivery,

transfers, lost to follow up, UDS data capture

Forms and Tools

• Form to explain the package• OB Payment Agreement• Estimation tool to help staff estimate

costs and payments• Greatest tool is to have an OB

Specialist build a relationship with the OB patients

• http://www.acog.org/

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