Insurance -- The Birth Cottage, LLC -- A Free-Standing Birth Centerserving Southern New Hampshire and Northern Massachusetts.

Insurance Billing

Superbill - Procedure Code Worksheet (pdf file)

Coding for Normal Pregnancy and Birth

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You have a client who has been seeing you for prenatal care, and you were the attendant at her labor and birth. Now she is 6 weeks postpartum and your care is ending. This is her second baby, and she had a confirmed pregnancy when she arrived in your care. You will bill the entire course of care to her insurance company at this point. It was uncomplicated from beginning to end.

Description:	ICD-9:	CPT:
Prenatal risk assessment	V22.1	99215 or H1000
Prenatal visits (date and bill each separately)	V22.1	59420
Prenatal bloodwork drawn	V22.1	36415
Lab handling fee	V22.1	99000
GBS screen	V22.1, 04102	87081
Normal delivery, uncomplicated	650	59409
Delivery of placenta	650	59414
Postpartum care	V24.0	59430
Newborn exam	V30.2	99432
2 home visits, postpartum	V24.0	99350 (each one)
Postpartum office visits, mother, 1 hr	V24.2	99215
Postpartum office visits, baby, 1 hr	V20.2	99215
6 week visit with pap	V24.0	99215
Pap smear	V76.2	88142
Or, if this is too difficult to break down or the insurance company does not want it unbundled, you can code it globally:
Global obstetric care	V22.1, 650	59400

Coding for Other Scenarios

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A client comes to you for prenatal care and is Rh negative with a partner who is Rh positive. She requires prenatal RhoGAM. Your billing would look like this:

	ICD-9	CPT	Example Amount
Office visit, established patient	V22.0 or 1, 656.13	99215	$75
Routine venipuncture	656.13	36415	$25
Lab handling fee	656.13	99000	$10
Prenatal RhoGAM	656.13	90384	$100
Sub-q injection of RhoGam	656.13	90471	$25

During the postpartum course, the billing would change somewhat. You can use the same codes to take postpartum blood, the lab handling fee, the medication, and the actual injection of the RhoGAM. The ICD-9 code would be 656.14 instead of 656.13.

During your routine prenatal care, your client requests a GBS screening test. Your billing would look like this:

Office visit, established patient	V22.1 or V22.0	99215	$75
GBS swab, vaginal/rectal		87081	$25
Lab handling fee		99000	$10
A client calls you to schedule a first visit. She is unsure of her pregnancy status, and would like a pregnancy test and to book care with you if positive. This is how it would look:
Office visit, new patient, complex	V72.4	99205	$150
Pregnancy test, urine	V72.4	81025	$5
Or, it could look like this:
Normal pregnancy, unconfirmed, office visit	V22	99205/H1000 (Medicaid)
Pregnancy test, urine	V22	81025
You see a new mother postpartum for care. She complains of nipple soreness, a baby who has a hard time with latch, and you find that the baby is losing weight and mildly dehydrated. She is there for counseling for her nursing difficulties, as well as postpartum care for both she and the baby. You can code like this:
Office visit for mother, complex	676.14	99215	$100
Office visit for baby, complex	7833, 7793	99215	$100
After the birth, the baby is not breathing and requires newborn resuscitation, then prolonged contact with caregivers postpartum. You perform a newborn exam as part of the routine care once the baby is stable.
Normal newborn care outside hospital	V30.2	99432	$250
Newborn resuscitation, PPV	77081	99440	$250
2 hours extended care	77081, 7706	99354	$75
		99355 (2)	$150

Medicaid Claims

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For a global midwifery fee, 59400, the reimbursement rate for Medicaid is $1200 as of 2005. If you were to unbundle this fee, and bill it individually, it would vary for reimbursement but would average quite a bit more. Below is an example of a claim that was recently processed and reimbursed. Yours may be a bit different depending on the care you gave and the quantity of visits.

Prenatal Risk assessment	99215	$67
Prenatal Visits, 8 total	99214	$58.73 each, $469.92 total
Prenatal labwork handling fee	99000	$3
Normal Delivery	59409	$900
Delivery of Placenta	59414	$56.40
Postpartum Care, Mom	59430	$20
Newborn Exam	99432	$40
2 home visits, 1 prenatal, 1 PP	99350	$79.21 each, $158.42 total
2 PP office visits, mother	99215	$67 each, $134 total
2 PP office visits, baby	99215	$67 each, $134 total
6 week visit with PAP	99215	$67 each, $134 total
Handling of PKU specimen	99000	$3
TOTAL:		$2052.74

Helpful Hints

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1. Make sure you fill out the form completely - keep a sample form handy from one that was successful so you know what works. Empty fields will automatically kick the entire claim back to you.

2. Every insurance company will have a specific number assigned to each individual provider. If you are not a participating provider, you will of course not have one. In its place, though, you will need to often enter something - a row of XXXÂs, for instance, or sometimes they will assign you a complimentary number you can enter into the appropriate field.

3. Typing is much better than hand writing. Take the time to type so there is no question as to what the claim has written on it.

4. You can always call the insurance company and tell them you are an out of network provider filing a claim with them. Ask what information, and in what fields, they want filled in. They will often be very helpful and tell you exactly how they want the claim to appear.

5. If you can bill electronically, it is worth the effort to get it set up. Computers will sort, pay, and send the check to you instead of having people enter the information into a system, actually see the claim and be able to deny or approve it, and make mistakes anywhere along the process. The less people involved, the better.

6. All of your CPT codes need to match the ICD-9 codes as to why the procedure was needed in the first place. Once you get pairs of codes that work for you, keep a log of them and use them again for future claims.

7. Call and check up on the claims after 3-4 weeks if you have not heard anything from the insurance company. They legally have 30 days from the time they receive the claim to respond to you in writing. If they do not, make sure you bring it to their attention. If you still have not heard after another 2 weeks, call again. The squeaky wheel gets the grease.

8. Anytime you call an insurance company, log the date, time, and person you spoke with. Also keep good notes on what was said, make sure they document the conversation as well, and put it in the chart with the claim. This is your legal record!

9. If you do not agree with the claim, the way it was handled, or the outcome of payment, you have the right to go to arbitration with an outside source. Do not take their answer as final! The chances of having a ruling overturned is greater than the chance of it not being overturned. Keep this in mind. Also, when threatened nicely with the chance of it going to arbitration, often their tune will change dramatically right then and there on the phone.