Coding

Expand all | Collapse all

NST reimbursement

  • 1.  NST reimbursement

    Posted 01-26-2020 14:57
    I practice in North Carolina at a large academic medical center. We have recently been informed that our OBGYN department is having issues with reimbursement for NSTs on term, low-risk uncomplicated patients (more of the rarity than the norm at our institution, but still a large enough portion of our patient pool) who present to OB triage to "rule out labor" or in "threatened labor" but ultimately go home. Up to now we had been using the "false labor at term" CPT codes but that no longer seems to be cutting it. Apparently it's become an issue with Medicaid patients, in particular.We reached out to our billing department, and their answer was that if the patient truly does not have any high-risk issues, and it's just normal pregnancy, there is not much to change, and that we just have to know that we will not get separately reimbursed for the NST. For clarity, we are using the appropriate CPT codes when there is any "high-risk" condition, even if it's as simple as "obesity in pregnancy." How do you suggest that we get reimbursed for the NST's in these cases? What CPT/ICD-10 codes should we be using?
    I recognize that this may not be an MFM-specific question but even some of our MFM full-scope prenatal patients might fall under this category.
    Thank you.  


    ------------------------------
    Angelica Glover
    ------------------------------


  • 2.  RE: NST reimbursement

    Posted 01-26-2020 19:59
    Hello,
    The coding committee does not give clinical advice. Nonetheless, in my opinion, I am not aware of a national guideline recommending a NST be done for rule out labor or rule out SROM. One might argue that the evaluation could have been done in the office and the FHR checked with a doptone. Putting the ICD-10 for high-risk pregnancy in these cases is not appropriate since you stated that these pregnancies were low-risk and uncomplicated. If a recognized  indication exists for doing a NST, then it may be billed with the corresponding ICD-10.

    ------------------------------
    Fadi Bsat
    ------------------------------



  • 3.  RE: NST reimbursement

    Posted 01-27-2020 09:18
    If there is any issue at all you can use the icd 10 code for high risk pregnancy in the 2/3rd trimester and it is reimbursed


    Shareece Davis-Nelson, MD
    Maternal Fetal Medicine
    Loma Linda University Health

    CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify me immediately by replying to this message and destroy all copies of this communication and any attachments. Thank you.





  • 4.  RE: NST reimbursement

    Posted 01-27-2020 10:01
    Hello,
    The asker stated the pregnancy is low-risk and uncomplicated. Such patients evaluated for preterm labor or PROM and the condition is ruled out do not have an indication for the NST (in my opinion). Using the ICD-10 for high risk pregnancy (O09.9 series) in this situation is not advised and may raise concerns if audited. Let's now assume the condition is confirmed, i.e. the patient does indeed has preterm labor and is admitted and placed on continuous FHR monitoring, then an NST should still not be billed because the FHR evaluation is part of the E/M. If PROM is confirmed and the patient is only intermittently monitored by NST (once or twice a day), then an NST may be billed when performed along with the corresponding ICD-10 for PROM (O42 series), +/- oligohydramnios (O41.0 series) if oligohydramnios is present.

    ------------------------------
    Fadi Bsat, MD
    ------------------------------



  • 5.  RE: NST reimbursement

    Posted 01-28-2020 08:28

    Good Morning

    As Fadi stated, we would NOT recommend utilizing high risk icd-10 codes in a low risk patient in order to obtain reimbursement.
    The committee has typically recommended the following (taken from our coding manual):
    When performing continuous electronic fetal monitoring, you cannot bill the non-stress test (59025) or contraction stress test (59020) code for these services.  Fetal monitoring is considered a labor management service and is included in the primary service (E/M, observation, etc.). The technique is similar to NST or CST since the fetal heart monitor is used for both. The procedures, however, are different with respect to coding. Fetal monitoring is considered a labor management service and is included in the primary charge (E/M, observation, etc.). Therefore, fetal monitoring is not separately billed or coded. 
    As Fadi noted, the patient is being evaluated in Ob triage, put on cEFM during this evaluation (for FHR/toco) but all of this 'work' is included in your E/M or obs or inpatient charge for that encounter.  If the patient is 'ruled out' for labor, you do not then bill the E/M code for that work AND an NST, the cEFM was part of your encounter.   Even with NST, and not just monitoring, there is always a question of what the purpose of testing a normal patient would be - whether there is any diagnostic value. Most payers now have diagnosis guidelines for NST, because providers have been billing them routinely for patients without risk. Especially with CMS payers, as Fadi noted, I would be concerned if the institution was audited, that this would be flagged. I think Fadi also provided some good clinical examples of when an NST could be billed in addition to an E/M visit.

    Hope that helps!
    thanks
    vanita



    ------------------------------
    Vanita Jain, MD
    Chair, SMFM Coding Committee
    ------------------------------



  • 6.  RE: NST reimbursement

    Posted 01-28-2020 10:21
    I apologize for any confusion.
    I was simply saying that if there is any billable code that makes the patient 'high risk (ie more than routine)' that the high risk code could be used. In my institution we have issues with patients carrying federally funded insurances getting covered for NSTs with risk factors that aren't included in the insurers narrow list of codes. So I use the high risk pregnancy code to include abnormal screening tests, women over the age of 40, black women with any additional risk for comorbidity, because the rates of stillbirth and adverse pregnancy outcomes are high enough to justify testing. 
    I do echo all that has also been said.
    Regards,


    Shareece Davis-Nelson, MD
    Maternal Fetal Medicine
    Loma Linda University Health

    CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify me immediately by replying to this message and destroy all copies of this communication and any attachments. Thank you.





  • 7.  RE: NST reimbursement

    Posted 01-28-2020 20:06
    Vanita, et.al., 
    As with anything, I am assuming now that the insurances are only paying for certain diagnostic codes. Is there now a magic list of such codes for NSTs?
    Allan Fisher, MD

    --
    Allan J Fisher, MD, FACOG, FACMG

    "None of us is as dumb as all of us." NASA

    "After this, there is no turning back. You take the blue pill - the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill - you stay in Wonderland, and I show you how deep the rabbit hole goes. Remember: All I'm offering is the truth."
    – Morpheus from The Matrix










  • 8.  RE: NST reimbursement

    Posted 01-29-2020 07:33
    Hi Allan
    Payers individually have lists of indications for the NST.  Aetna has the most easily accessible one for 59025 with icd-10 codes they traditionally approve (last reviewed 4/2019) - Antepartum Fetal Surveillance.  In short there is no "magic list" - yet!
    The Coding Committee has put together a task force to create our own list of ICD-10 indications for major imaging studies.
    We are awaiting for an antenatal surveillance updated document - which we are told is in progress/anticipated for this year.
    In the interim we are planning to review what we consider (based on published practice parameters) appropriate IcD-10 indications for the 76811, 76805 (as these are already published), and likely 76825.
    This particular issue had to do with when you see a patient for a "labor" issue - is the evaluation of the fetal monitoring considered part of your "labor evaluation" E/M or is it a separately billable NST service (with separate indication)?  The Coding Committee's opinion has been, and remains, that when you are seeing the patient in Ob triage or an Ob ER for an acute medical concern or "labor check" that fetal monitoring you do is part of the overall E/M visit for that day.  We do not feel there is a separately billable NST charge.

    ------------------------------
    Vanita Jain, MD
    Chair, SMFM Coding Committee
    ------------------------------