Accurate diagnosis can have a significant impact on the midwifery practice's claim for billing. It is evident to us that coding and billing are among the most crucial elements in every midwifery clinic. The accuracy within each of them is essential to ensure the safety of patients, quick payments and effective operations.
 
Historically speaking midwives, other health care providers and payers were on the same page' with regard to fee-for-service reimbursements. Midwives performed a task and the they earned the payment. Simple and straightforward. However, with reforms in healthcare is the requirement for health care professionals to be precise and thorough in the diagnosis codes they use. The shift to pay-for-performance (P4P) programs, originally initiated by the CMS, but increasingly adopted by private payers, demands this accuracy. Along with offering incentives to Midwives for providing quality care, there are now penalties for midwives and other health care professionals who may not be offering patient care of acceptable quality. With this reform, accurate diagnosis became a top priority in order for midwives to claim bills accurately, here’s the reasons why.

Accuracy Was Always an Issue
While accurately recording diagnosis codes has always been important, until P4P programs, many payers accepted marginally thorough supporting information to approve claims and pay providers. The new emphasis on claims clarity often proves to be challenging for midwives and billing staff, particularly for those providers not in the habit of submitting fully documented reimbursement claims.
In the past, claims with faulty diagnosis codes typically were denied. Yet, some insufficiently explained claim submissions slipped through and were approved. If payer claim reviewers were hurried into claim examinations, it was always possible that some submissions that could have had payers ‘scratching their heads’ were approved.
 
However, most of the diagnosis coding rules have changed. Accuracy, always a factor, has become the primary component of claims approval. Along with approved/rejected decisions, medical providers now face quality care issues, requiring further justification and explanation to eliminate payer confusion.

Proper Diagnosis Critical for Payment
Some midwives and billing personnel seem forgetful that Medicare Advantage plans pay, in part, as a function of the number and severity of sickness in the total population of patients. CMS calculates variable per month payments based on the levels of the ‘sick’ population. Some private payers are endorsing this approach, demanding that physician diagnosis coding ‘fits’ the matrix.
 
While some midwives during the fee-for-service era always went the extra mile to fully explain their diagnostic coding and process, many other providers, often because of billing staff time constraints, neglected to thoroughly document their diagnosis procedures. However, providers now risk facing claim denials with P4P programs if payer review staff is unsure that the doctor performed diagnostic services that were necessary to design a treatment plan.
 
Accurate and thorough coding for chronic conditions is another prime area of payer scrutiny. ICD-9 guidelines require providers to use these codes ‘as often as applicable’ when treating chronic conditions. P4P quality care evaluation depends on proper use of these codes. The penalty consequences of taking coding ‘shortcuts’ can result in lower income for the midwife.
 
These are some of the reasons that using accurate diagnosis codes are critical for maximum claim approvals and CMS decisions that physician care qualifies as meeting quality guidelines. The strong focus on procedural diagnostic coding accuracy is here—possibly affecting your compliance and income levels.
 
Accurate diagnosis coding, backed up by thorough documentation regarding the necessity of diagnostic procedures, is no longer a payer ‘luxury.’ Accuracy and clarity are now a necessity for all physicians. Achieving this result typically demands some combination of the following actions.

• Designing an almost foolproof internal procedure for billing staff or midwives to review all claim submissions for accurate diagnosis codes and supporting document clarity.
• Have experienced coders review EHR document derived diagnostic codes before submitting claims.
• Retaining a leading independent coding and documentation firm, to assume the responsibility of submitting accurate, clearly explained diagnostic procedure claims for you.
• Midwives developing the habit of fully documenting all diagnostic procedures for every patient, helping billing staff and payer reviewers to understand the reasons for the diagnosis process used.

 
Midwives and other healthcare practices using these tips should remain in HIPAA, CMS and P4P compliance, maintain or increase revenue and create evidence of delivering quality care to all patients. Properly using diagnosis codes and supporting your diagnostic procedures with valid documentation will achieve these results.

Reference

Diagnosis coding has taken center stage in medical billing. Coronis. (n.d.). Retrieved September 29, 2022, from https://www.coronishealth.com/blog/diagnosis-coding-has-taken-center-stage-in-medical-billing/ 

Regulations are used to safeguard and enhance the lives of businesses, individuals as well as the environment, and to help boost economic growth. In order to fully protect everyone’s interest within certain organization, regulations must be updated from time to time if there’s a need. Medical billing may indirectly impact the healthcare industry, but it is important to maintain order and organization in the industry.
 
To become an effective biller, one must understand the different billing regulations, private and public insurance plan policies. Here are new billing regulations for 2022 every biller as well as customers must be aware of.

1. No Surprises Act Comes into Effect on January 01, 2022
 
Beginning January 1, 2022, midwives and other health care providers will be required by law to give uninsured and self-pay patients a good faith estimate of costs for services that they offer, when scheduling care or when the patient requests an estimate.
 
This new requirement was finalized in regulations issued October 7, 2021. The regulations implement part of the “No Surprises Act,” enacted in December 2020 as part of a broad package of COVID- and spending-related legislation. The act aims to reduce the likelihood that patients may receive a “surprise” medical bill by requiring that providers inform patients of an expected charge for a service before the service is provided. The government will also soon issue regulations requiring midwives and other healthcare professionals to give good faith estimates to commercial or government insurers, when the patient has insurance and plans to use it.
Midwives working in group practices or larger organizational settings and facilities will likely receive direction from their compliance department or lawyers on how to satisfy this new requirement.
 
Its implementation means that patients can no longer be held accountable for emergency services from out-of-network providers or out-of-network hospital services (including ambulance services and emergency room physicians). It also implies that patients should not be liable for ‘balance billing’ by an in-network healthcare facility for services received from out-of-network providers (such as radiologists, anesthesiologists, pathologists, or neonatologists).
 
2. CMS Announces Lower Medicare PFS conversion factor
 
The CY 2022 conversion factor will be $33.59, a decrease of $1.30 over the CY 2021 conversion factor. But it’s not just this cut that will impact medical practice revenues in 2022. It’s estimated that the combined effect of the PFS cuts since 2021, as well as the 4 percent Statutory Pay-As-You-Go (PAYGO) cut and the 2 percent cut for Medicare sequestration, will lower medical practice revenues by 10 percent.
 
3. Modifications in POS codes for Telehealth
 
The point of service (POS) codes for telehealth will see two main changes. POS 02 has been revised for cases when the telehealth consult occurs outside the patient’s home. POS 10 has been introduced to cover telehealth consults while the patient is home.
 
4. Split (or Shared) E/M Visits
 
CMS has stipulated that in 2022 the provider who handles the substantial portion of the visit (which could be on any of the three components – the time spent on history, exam, or medical decision making), or more than half of the total time spent, would bill for the visit.
 
5. Direct Billing of Physician Assistant (PA) Services
 
Beginning January 01, 2022, PAs can bill Medicare directly for their services and reassign payment for their services. Currently, payments for services delivered by PAs are made by Medicare to their employers.
 
These are just a handful of medical coding and billing changes you can expect in the coming year. Keeping track of these changes and training your staff will be crucial to ensuring that your medical practice revenues don’t dip in 2022.  If you’re wondering how you’ll stay on top of these medical billing changes in your medical practice, now is an excellent time to partner with an experienced medical billing service. 
 
References

American Psychological Association. (2021, December 10). New billing disclosure requirements take effect in 2022. https://www.apaservices.org. Retrieved September 27, 2022, from https://www.apaservices.org/practice/legal/managed/billing-disclosure-requirements

Blog, P. F. (2021, December 27). 5 top medical billing changes in 2022. Medical billing and collections as low as 1.99%. Retrieved September 27, 2022, from https://practiceforces.com/blog/medical-billing-changes-in-2022/ 

Privacy matter is critical to all healthcare providers, much especially for midwives. Our patient entrusts their lives to us that is why trust becomes a huge part of patient- midwife relationship that should not be neglected. Ensuring that all patient data are properly collected and well protected is our huge responsibility. It comes with patient confidentiality that is important for both patients and midwives, and it preserves the integrity of the midwifery community.
 
The U.S. healthcare system has never had a shortage of problems – it has always dealt with several issues simultaneously. The exorbitant prices, the lack of price transparency, medical identity theft cases, lack of patient identification in hospitals, preventable medical errors, and archaic laws are just some issues that plague healthcare. Healthcare data breaches have unfortunately been growing at an exponential rate. With no signs of them stopping anytime soon, it becomes crucial that healthcare providers, `professionals, and everyone involved with patient information be vigilant regarding protecting the data.
 
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. This is as important to the healthcare industry now more than ever — if not more. Hospitals, insurance companies and healthcare providers all need to ensure HIPAA compliance to safeguard private and sensitive patient data. 
 
HIPAA introduced a number of important benefits for the healthcare industry to help with the transition from paper records to electronic copies of health information. HIPAA has helped to streamline administrative healthcare functions, improve efficiency in the healthcare industry, and ensure protected health information is shared securely.
 
The HIPAA legislation had four primary objectives:

• Assure health insurance portability by eliminating job-lock due to pre-existing medical conditions
• Reduce healthcare fraud and abuse
• Enforce standards for health information
• Guarantee security and privacy of health information

The Privacy Rule standards address the use and disclosure of individuals’ health information (known as “protected health information”) by entities subject to the Privacy Rule. These individuals and organizations are called “covered entities.” The Privacy Rule also contains standards for individuals’ rights to understand and control how their health information is used. A major goal of the Privacy Rule is to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well-being. The Privacy Rule strikes a balance that permits important uses of information while protecting the privacy of people who seek care and healing.

Your practice, not your electronic health record (EHR) vendor, is responsible for taking the steps needed to comply with HIPAA privacy, security standards, and the Centers for Medicare & Medicaid Services’ (CMS’) Meaningful Use requirements. Read up on laws governing the privacy and security of health information. You must comply with all applicable federal, state, and local laws.

Below are the steps how you and your practice become HIPAA compliant

       1. Create Privacy and Security Policies for the PracticeBecoming HIPAA compliant requires more than simply following HIPAA Security and Privacy Rules. Covered entities and business associates must also prove that they’ve been proactive about preventing HIPAA violations by creating privacy and security policies. These policies must be documented, communicated to staff, and regularly updated. Staff must be trained on HIPAA policies during orientation and at least once a year, and they must attest (in writing) that they understand all HIPAA policies and procedures.
Healthcare organizations are also required to create and distribute a Notice of Privacy Practices (NPP) form for patients to review and sign. The NPP should outline the covered entity’s privacy policies, including how PHI is handled, and notify patients of their right to access copies of their medical records.

       2. Name a HIPAA Privacy Officer and Security Officer
HIPAA legislation is complicated and ever-changing, so every healthcare organization needs its own internal HIPAA experts. The HIPAA Security Rule requires covered entities to designate a Privacy Compliance Officer to oversee the development of privacy policies, ensure those policies are implemented and update them annually. HHS suggests that larger organizations also form a Privacy Oversight Committee to help guide policy creation and manage oversight. The Privacy Officer and Oversight Committee members must undergo regular training to stay abreast of changes to HIPAA regulation. The HIPAA Privacy Officer is also responsible for maintaining NPPs, managing and updating BAAs, scheduling training sessions and self-audits, and otherwise ensuring that the organization is compliant with the HIPAA Privacy Rule.
Covered entities are also required to have a HIPAA Security Officer to ensure there are policies and procedures in place to prevent, detect, and respond to ePHI data breaches. The Security Officer establishes safeguards required by the Security Rule and conducts risk assessments to gauge their effectiveness.

       3. Implement Security Safeguards
The Security Rule requires three types of safeguards that covered entities and business associates must have in place to secure ePHI — including:

• Administrative Safeguards: Organizations must document security management processes, designate security personnel, adopt an information access management system, provide workforce security training, and periodically assess all security protocols
• Physical Safeguards: Organizations must be able to control who has access to physical facilities where ePHI is stored. They must also secure all workstations and devices that store or transmit ePHI.
• Technical Safeguards: Organizations must have access controls to secure ePHI in the EHR and other databases to ensure employees only see data they’re authorized to see. Data must be encrypted when it is at rest and during transit, which creates the need for secure email, HIPAA Compliant Texting, and HIPAA Compliant Messaging solutions. Organizations must also have audit controls for all hardware and software that manage or transmit ePHI to ensure they meet HIPAA network requirements. And there must be integrity controls to ensure ePHI is not improperly edited or deleted.

      4. Regularly Conduct Risk Assessments and Self-Audits
Becoming HIPAA compliant is not a one-and-done process. HHS requires covered entities and business associates to conduct regular (at least annual) audits of all administrative, technical, and physical safeguards to identify compliance gaps. Organizations must then create written remediation plans that clearly explain how they plan to reverse HIPAA violations and when this will happen.

      5. Maintain Business Associate Agreements
Before sharing PHI with business associates, covered entities must obtain “satisfactory assurances” that the business associate is HIPAA-compliant and can effectively safeguard the data, and the parties must enter a BAA. All BAAs must be reviewed annually and updated to reflect any changes in the nature of the business associate relationship.

      6. Establish a Breach Notification Protocol A HIPAA violation doesn’t always get organizations into trouble, especially if they can prove the breach was unintentional and that they did everything in their power to prevent such breaches. But failing to report breaches makes the situation worse. The HIPAA Breach Notification Rule requires covered entities and business associates to report all breaches to OCR and to notify patients whose personal data might have been compromised. HIPAA-beholden organizations are required to have a documented breach notification process that outlines how the organization will comply with this rule.

      7. Document Everything
Organizations must document all HIPAA compliance efforts — including privacy and security policies, risk assessments and self-audits, remediation plans, and staff training sessions. OCR will review all this documentation during HIPAA audits and complaint investigations. HIPAA compliance is critical for healthcare organizations, not only to protect patient privacy but also to protect the bottom line. To keep data safe, healthcare providers need to know how to become HIPAA compliant, and they need technology partners who take it just as seriously as they do.
 
Our duty as midwives is not only to provide our client with quality care but protecting their information as well. We must comply these set of rules not only to follow the law, but to safeguard confidentiality and individuality.

Learn more about HIPAA  https://www.healthit.gov/sites/default/files/pdf/privacy/onc_privacy_and_security_chapter4_v1_022112.pdf
 
References

• Centers for Disease Control and Prevention. (2018, September 14). Health Insurance Portability and accountability act of 1996 (HIPAA). Centers for Disease Control and Prevention. Retrieved June 18, 2022, from https://www.cdc.gov/phlp/publications/topic/hipaa.html#:~:text=The%20Health%20Insurance%20Portability%20and,the%20patient's%20consent%20or%20knowledge.
• Gibson, M. (2021, July 2). How to protect patient data at your hospital. RightPatient. Retrieved June 18, 2022, from https://www.rightpatient.com/blog/how-to-protect-patient-data-at-your-hospital/
• Health Insurance Portability & Accountability Act (HIPAA): Cutting edge document destruction. Cutting Edge Document Destruction |. (2011, November 24). Retrieved June 18, 2022, from https://cuttingedgedd.com/legislation/health-insurance-portability-accountability-act-hipaa/
• TigerConnect on June 17, 2020. (2022, January 14). How to become HIPAA compliant (step-by-step guide). TigerConnect. Retrieved June 18, 2022, from https://tigerconnect.com/blog/how-to-become-hipaa-compliant-step-by-step-guide/
• Why is HIPAA important? HIPAA Journal. (2022, March 16). Retrieved June 18, 2022, from https://www.hipaajournal.com/why-is-hipaa-important/#:~:text=HIPAA%20helps%20to%20ensure%20that,who%20it%20is%20shared%20with

Coding and billing for maternity obstetrical care is quite a bit different from other sections of the American Medical Association Current Procedural Terminology (CPT). Maternity care services typically include antepartum care, delivery services, as well as postpartum care. Depending on the patient’s circumstances and insurance carrier, the provider can either:

• Submit all rendered services for the entire nine months of services on one CMS-1500 claim form.
• Submit claims based on an itemization of maternity care services.

The Global Obstetrical PackageWhen discussing maternity obstetrical care medical billing, it is crucial to understand the Global Obstetrical Package.
Most insurance carriers like Blue Cross Blue Shield, United Healthcare, and Aetna reimburses providers based on the global maternity codes for services provided during the maternity period for uncomplicated pregnancies.
Currently, global obstetrical care is defined by the AMA CPT as “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” (Source: AMA CPT codebook 2022, page 440.)
If the services rendered do not meet the requirements for a total obstetric package, the coder is instructed to use appropriate stand-alone codes. These might include antepartum care only, delivery only, postpartum care only, delivery and postpartum care, etc.
When billing for the global obstetrical package code, all services must be provided by one obstetrician, one midwife, or the same physician group practice provides all of the patient’s routine obstetric care, which includes the antepartum care, delivery, and postpartum care.
Here a “physician group practice” is defined as a clinic or obstetric clinic that is under the same tax ID number. It uses either an electronic health record (EHR) or one hard-copy patient record. Each physician, nurse practitioner, or nurse midwife seeing that patient has access to the same patient record and makes entries into the record as services occur.
Individual Evaluation and Management (E&M) codes should not be billed to report maternity visits unless the patient presents for issues outside the global package.
All prenatal care is considered part of the global reimbursement and is not reimbursed separately. The provider will receive one payment for the entire care based on the CPT code billed.
Services Bundled with the Global Obstetrical PackageA key part of maternity obstetrical care medical billing is understanding what is and is not included in the Global Package.
Services provided to patients as part of the Global Package fall in one of three categories. They are:

• Antepartum care: Care given from conception, up to (not including) the delivery of the fetus.
• Intrapartum care: Inpatient care of the passage of the fetus and placenta from the womb.
• Postpartum care: Care of the mother after delivery of the fetus.

Antepartum CareAntepartum care comprises the initial prenatal history and examination, as well as subsequent prenatal history and physical examination. This includes:

• All routine prenatal visits until delivery ( ≈ 13 encounters with patient)
  • Monthly visits up to 28 weeks of gestation
  • Biweekly visits up to 36 weeks of gestation
  • Weekly visits from 36 weeks until delivery
• Recording of weight, blood pressures and fetal heart tones
• Routine chemical urinalysis (CPT codes 81000 and 81002)
• Education on breast feeding, lactation and pregnancy (Medicaid patients)
• Exercise consultation or nutrition counseling during pregnancy

IMPORTANT: Any other unrelated visits or services within this time period should be coded separately.
Intrapartum Care AKA Labor & DeliveryLabor and delivery include:

• Admission to the hospital including history and physical
• Inpatient evaluation and management (E/M) services provided within 24 hours of delivery
• Management and fetal monitoring of uncomplicated labor
• Administration/induction of intravenous oxytocin (performed by provider not anesthesiologist)
• Insertion of cervical dilator on same date as delivery, placement catheterization or catheter insertion, artificial rupture of membranes
• Vaginal, cesarean section delivery, delivery of placenta only (the operative report)

NOTE: For any medical complications of pregnancy, see the above section “Services Bundled into Global Obstetrical Package.”
Postpartum CarePostpartum care includes the following:

• Uncomplicated inpatient visits following delivery
• Repair of first- or second-degree lacerations (for lacerations of the third or fourth degree, see “Services Bundled into Global Obstetrical Package”)
• Simple removal of cerclage (not under anesthesia)
• Routine outpatient E/M services that are provided within 6 weeks of delivery (check insurance guidelines for exact postpartum period)
• Discussion of contraception prior to discharge
• Outpatient postpartum care – Comprehensive office visit
• Educational services, such as breastfeeding, lactation, and basic newborn care
• Uncomplicated treatments and care of nipple problems and/or infection

IMPORTANT: All of the above should be billed using one CPT code. Separate CPT codes should not be reimbursed as part of the global package.

Services Excluded from the Global Obstetrical PackageCertain maternity obstetrical care procedures are either highly complex and/or not required by every patient. As such, including these procedures in the Global Package would not be appropriate for most patients and providers.  The American College of Obstetricians and Gynecologists (ACOG) has developed a list of procedures that are excluded from the global package. If the provider performs any of the following procedures during the pregnancy, separate billing should be done as these procedures are not included in the Global Package.

• Initial E/M to diagnose pregnancy if antepartum record is not initiated at this confirmatory visit
  • This confirmatory visit (amenorrhea) would be supported in conjunction with the use of ICD-10-CM diagnosis code Z32.01.
  • This is usually done during the first 12 weeks before the ACOG antepartum note is started. Use CPT Category II code 0500F.
• Laboratory tests (excluding routine chemical urinalysis)
  • Examples include CBC, liver functions, HIV testing, Blood glucose testing, sexually transmitted disease screening, and antibody screening for Rubella or Hepatitis, etc.
• Maternal or fetal echography procedures
• Obstetric ultrasound, NST, or fetal biophysical profile
  • Depending on the insurance carrier, all subsequent ultrasounds after the first three are considered bundled
• Cerclage, or the insertion of a cervical dilator more than 24 hours from admission.
• External cephalic version (turning of the baby due to malposition)
• Amniocentesis (any method)
• Amnioinfusion
• Chorionic villus sampling (CVS)
• Fetal contraction stress test
• E/M services for management of conditions unrelated to the pregnancy during antepartum or postpartum care. The diagnosis should support these services.
  • Examples include cardiac problems, neurological problems, diabetes, hypertension, hyperemesis, preterm labor, bronchitis, asthma, and urinary tract infection
  • NOTE: These encounters could be office visits, clinic visits, emergency room, or inpatient admission/observation.
• Inpatient E/M services provided more than 24 hours before delivery
• Surgical Procedures during pregnancy
  • Examples include urinary system, nervous system, cardiovascular, etc.
• Laceration repair of a third- or fourth-degree laceration at the time of delivery
  • Per ACOG coding guidelines, this should be reported using modifier 22 of the CPT code used to bill.
• Contraceptive management services (insertions)

Split Care Performed/Itemization BillingSome patients may come to your practice late in their pregnancy. Others may elope from your practice before receiving the full maternal care package. In such cases, your practice will have to split the services that were performed and bill them out as is. Examples of situations include:

• The patient has received part of her antenatal care somewhere else (e.g. from another group practice).
• The patient leaves her care with your group practice before the global OB care is complete.
• Patient receives care from a midwife but later requires MD-level care.
• The patient has a change of insurer during her pregnancy.

In these situations, your practice should contact the insurance carrier and notify them of these changes. This will allow reimbursement for services rendered.
If the patient had fewer than 13 encounters with the provider, your practice should contact the insurer to find out whether the insurer will honor the global package CPT code. Possible billings include:

• Antepartum care only. The following CPT codes apply based on how many visits a patient had with your practice:
  • 59425: Antepartum care only, 4-6 visits
  • 59426: Antepartum care only, 7 or more visits; E/M visit if only providing 1-3 visits
• Delivery only: CPT codes 59409, 59514, 59612, and 59620
• Postpartum care only: CPT code 59430

Diagnosis Codes for Deliveries and Related Services

• Reporting Routine Prenatal Visits: routine prenatal visits are reported with a code from category Z34.- It should always be the first-listed diagnosis code unless the patient has other medical conditions affecting the pregnancy. Note that Z34.- codes should never be reported with an O code.
• Outcome of Delivery: should be included when a delivery has occurred (ICD-10-CM Z37.-).
• Normal Delivery (ICD-10-CM O80): only for full-term normal delivery and delivers a single, healthy infant. Additionally, there are no complications in the antepartum period, during the delivery, or in the postpartum period during the delivery encounter.
  • If O80 is not appropriate, the primary diagnosis should reflect the main circumstances or complications of the delivery.
  • If the patient is admitted with condition resulting in cesarean, then that is the primary diagnosis.
  • If admitted for other reason, the admitting diagnosis is primary for admission and reason for cesarean linked to delivery.
  • If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis.
• O Codes: An O code from ICD-10-CM Chapter 15 – “Pregnancy, Childbirth & the Puerperium” should always be reported for the delivery when the patient has experienced any current complication in the antepartum period, during the delivery, or in the postpartum period.
• All conditions treated or monitored can be reported (e.g., gestation diabetes, pre-eclampsia, prior C-section, anemia, GBS, etc.)

Who Is Eligible to Provide Patient Care?The following is a comprehensive list of eligible providers of patient care (with the exception of residents, who are not billable providers):

• Obstetrician, Maternal Fetal Specialist, Fellow
• Certified Nurse Midwife (CNM)
• Nurse Practitioner Midwife (NPM)
• Certified Professional Midwife (CPM)

ModifiersDepending on your state and insurance carrier (Medicaid), there may be additional modifiers necessary to report depending on the weeks of gestation in which patient delivered. Before completing maternity obstetrical care billing and coding, always make sure that the latest OB guidelines are retrieved from the insurance carrier to avoid denials or short pays.

In order to ensure proper maternity obstetrical care medical billing, it is critical to look at the entire nine months of work performed in order to properly assign codes. Pay special attention to the Global OB Package. The coder should have access to the entire medical record (initial visit, antepartum progress notes, hospital admission note, intrapartum notes, delivery report, and postpartum progress note) in order to review what should be coded outside the global package and what is bundled in the Global Package. The key is to remember to follow the CPT guidelines, correctly append diagnoses, and ensure physician documentation of the antepartum, delivery and postpartum care and amend modifier(s).

Insurance fraud is any act made to deceive an insurance procedure. It occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that is due. It is also a deliberate deception perpetrated against or by an insurance company or agent for the purpose of financial gain. Fraud may be committed at different points by applicants, policyholders, third-party claimants, or professionals who provide services to claimants. Insurance agents and company employees may also commit insurance fraud. Common frauds include “padding,” or inflating claims; misrepresenting facts on an insurance application; submitting claims for injuries or damage that never occurred; and staging accidents.
People who commit insurance fraud include:

• organized criminals who steal large sums through fraudulent business activities,
• professionals and technicians who inflate service costs or charge for services not rendered, and
• ordinary people who want to cover their deductible or view filing a claim as an opportunity to

Inside the healthcare industry lies good opportunity for insurance fraud as well. Insurance fraud causes tens of billions of dollars in losses each year. It can raise health insurance premiums, expose you to unnecessary medical procedures, and increase taxes. If you’re in the healthcare industry, you must learn to identify what are the common types of healthcare and insurance fraud.

Common types of healthcare and insurance fraud
1. Fraud Committed by Medical Providers

• Double billing: Submitting multiple claims for the same service
• Phantom billing: Billing for a service visit or supplies the patient never received
• Unbundling: Submitting multiple bills for the same service
• Upcoding: Billing for a more expensive service than the patient actually received

​2. Fraud Committed by Patients and Other Individuals

• Bogus marketing: Convincing people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan
• Identity theft/identity swapping: Using another person’s health insurance or allowing another person to use your insurance
• Impersonating a health care professional: Providing or billing for health services or equipment without a license

3. Fraud Involving Prescriptions

• Forgery: Creating or using forged prescriptions
• Diversion: Diverting legal prescriptions for illegal uses, such as selling your prescription medication
• Doctor shopping: Visiting multiple providers to get prescriptions for controlled substances or getting prescriptions from medical offices that engage in unethical practices

 
How to Prevent Insurance Fraud?
 
The Affordable Care Act of 2010 included fraud-fighting efforts, such as allowing the U.S. Department of Health and Human Services (HHS) to exclude providers who lie on their applications from enrolling in Medicare and Medicaid and the Improper Payments Elimination and Recovery Act, which requires agencies to conduct recovery audits for programs every three years and develop corrective action plans for preventing future fraud and waste.
Other efforts included:

• Implementing an Automated Provider Screening system to review enrollment applications;
• Allowing HHS to impose a temporary moratorium on newly enrolled providers or suppliers, if necessary to combat fraud;
• Authorizing the Centers for Medicare and Medicaid Services, in conjunction with the Office of the Inspector General, to suspend payments to providers or suppliers during the investigation of a credible allegation of fraud; and
• Ensuring that providers and suppliers found guilty of fraud in one of the Centers’ systems, such as Medicare, cannot have service privileges in another area, such as Medicaid, or within state programs.

 
Additionally, in 2012, HHS and the Department of Justice formed the National Fraud Prevention Partnership to combat health care fraud. The group also consists of private and public groups such as health care companies and their organizations, the National Association of Insurance Commissioners, the National Insurance Crime Bureau and the National Health Care Anti-Fraud Association. The groups will share information on claims from Medicare, Medicaid. and private insurance to be administered by a third-
party vendor.
 
Fraudulent acts have no escape with the law. Whether you’re a healthcare provider trying to slip away money from your clients, or a client who doesn’t one to compensate the services provided to you.  Either way, one must be vigilant enough to take part in protecting his/her right and preventing these things to happen.  Keep all your records intact and avoid providing your information to anyone asking for it. Always verify, verify, verify!
 
References
Background on: Insurance fraud. III. (n.d.). Retrieved June 18, 2022, from https://www.iii.org/article/background-on-insurance-fraud
 

One significant role of a midwife is providing mothers with quality of health services. It is our duty to provide them with proper care and comfort making sure that their pregnancy journey will be a memorable one. There are many more maternal billing and coding challenges that you may encounter much especially during this pandemic. You’ve got to figure out a way to provide prenatal checkups, physical exams, annual well checks, and vaccinations because both your patient’s health and your practice’s revenue are at stake.

Global maternity care includes pregnancy-related antepartum care, admission for labor and delivery care, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care until six weeks postpartum. When billing for maternity care, it is crucial to understand the Global Obstetrical Package. Currently, global obstetrical care is defined by the AMA CPT as “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” (Source: AMA CPT codebook 2022, page 440.) All services must be provided by a provider with all of the patient’s routine obstetric care, which includes the antepartum care, delivery, and postpartum care.

Global Billing with CPT Code 59400-59618 Includes These Services
The Global OB package covers patient care during the entire pregnancy — the antepartum period, delivery, and postpartum. Providers get paid a flat rate for the services rendered under these CPT global obstetric codes:

• 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care
• 59510 – Routine obstetric care including antepartum care, cesarean delivery and postpartum care
• 59610 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care, after previous cesarean delivery
• 59618 – Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery

When billing with the global OB codes, front desk staff, coders and billers need to be aware of visits and services that aren’t part of routine maternity care. This allows schedulers to provide accurate information on possible patient costs and billers to charge separately. Proper global package code selection is essential to receive the maximum allowed reimbursement. There are times when one code might be paid but using the correct code will bring higher insurance payment. For example, if a patient has a cesarean delivery after an unsuccessful attempt at a vaginal delivery, code 59510 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, 67.00 relative value units) is in order. 
 
However, if this same scenario transpires after a prior cesarean delivery, 59618 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery, 67.88 RVUs) is the proper code to use.

CPT Code 59400 Includes Only Uncomplicated Services
It’s important to note, global maternity billing covers services under normal, uncomplicated conditions. Global maternity billing does not cover:

• Problems that aren’t related to pregnancy, such as yeast infections
• Services for pregnancy complications, such as gestational diabetes or toxemia
• Extra visits for a high-risk pregnancy
• Procedures, such as ultrasounds and amniocentesis

Instead, the provider would separately bill these services at the time of treatment.

Insurers Vary on CPT Code 59400 Billing, Payment Schedule, Duration
Global billing for maternity care is beneficial to both patient and provider when the pregnancy follows an uncomplicated course. Some variables, however, can complicate matters for the provider’s revenue cycle. Considering the global maternity billing package spans a nine-month period, that’s a big window to wait for reimbursement. Variables to consider with insurance companies when billing for global maternity services are:

• Not all insurance companies handle global maternity billing the same way.
• Not all insurers pay providers at the same interval. Some pay at the start of the pregnancy while others pay after the final postpartum visit is complete.
• Insurers differ on the coverage of specific services and duration of the global pricing bundle.

CPT Code 59400 Doesn’t Always Apply 
The CPT OB bundles are billed for and reimbursed when all services are rendered by a single providers or multiple providers from the same group. There are some situations that complicate global maternity billing and require the provider to bill the delivery, antepartum, and postpartum separately. These include when a:

• patient must change insurance providers or doctors during her pregnancy
• patient’s baby is delivered by someone other than her provider or another provider in a group practice
• patient has a voluntary or involuntary pregnancy termination

 
Global Maternity Care Code Quick Reference Guide
https://www.bcbsnd.com/content/dam/bcbsnd/documents/general/Global-Maternity-Quick-Reference-Guide.pdf
 
References
1, P. O. (2022, April 1). CPT code 59400 Global Maternity Billing You Need To Know. Healthcare Training Leader. Retrieved May 30, 2022, from https://healthcare.trainingleader.com/2019/10/cpt-code-59400/

Billing is a function that is critical for the financial cycle of all health care providers including midwives. It requires attention to detail and experience with the electronic and paper systems used in billing healthcare services. It is clear that understanding billing procedure is important to you as a midwife. While you may see a lot of billing courses online and in some institutions, billing for your own practice is crucial and time consuming that may affect your practice as well.

Hiring a biller company could be an option that you can consider for your midwifery practice. If you will hire a biller company you can avoid doing everything on your practice like submitting timely medical claims to insurance companies and payers such as Medicare and Medicaid, preparing, reviewing, and transmitting claims using billing software, including electronic and paper claim processing, setting up patient payment plans and work collection accounts, updating billing software with rate changes, updating cash spreadsheets, and running collection reports and so many grueling tasks that will greatly affect your services.

However, after you reached into the decision of hiring a biller company, the next consideration you should deliberate is asking “who will you hire?” Do you have any specific criteria based on your needs? Background checking with their previous clients, did they encounter previous issues and how they were able to overcome those issues. To help you with that, here are some questions that you can ask a biller company before hiring them for your midwifery practice.

1.    What will it cost?
This is always the main thing on everyone’s mind. The rate should be under 8% of collected charges. A percentage is a better option than a flat rate—the percentage usually goes down as your collections go up. Also ask about start-up fees, termination fees, data conversion fees, and any other additional costs. Some companies charge extra for patient collections follow up and other services.

2.    Can they provide references? 
Have they worked with practices that are similar to yours in size, scope, and/or specialty? Do they have testimonials, or can you call someone directly for a reference?

3.    Who owns your billing data? 
Your billing data should belong to you, and you should be able to take it with you if you choose to change services or bring your billing in-house.

4.    What kind of training does the staff have? 
Are they certified? What type of ongoing training do they receive? Are they using the most up-to-date resources and guidebooks (i.e., CPT, HCPCS, etc.)?

5.    Do they have any professional affiliations?
Does the service, or its employees, maintain any professional affiliations such as HBMA?

6.    Do they have a compliance plan in place? 
Are they HIPAA compliant? What are their security protocols?

7.    Who will actually be working on your account? 
Can you meet (on the phone or in person) the actual people who will be working on your account?

8.    Can you get a guarantee of transparency? 
How often will you receive reports showing the financial state of your business and the billing service’s progress? How will they communicate with you and how involved will you be in the billing processes?

9.    Are most of their services electronic? 
In this day and age, most of the processes should be electronic from eligibility verification to remittances. They should also offer credit card processing and online bill pay for patients.
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10. Are there billing follow up items that they don’t handle?
Don’t assume that a billing service will do everything or that everything is included in your rate. Ask up front and be sure you know if there are services that they don’t offer.
There are a lot of choices out there. You may have some questions that are specific to your needs, but the following ten questions should apply to any practice. Ask them to each service you speak with and then compare the answers. Use these questions to help guide your decision when selecting a medical billing service. It’s worth it to take your time evaluating your options so that you get the best service possible from the start.

Additional Resources
Lea Chatham Lea writes educational articles to help medical practices improve their businesses. In addition to Kareo. (2013, February 26). 10 questions to ask before hiring a medical billing service. Kareo. Retrieved May 13, 2022, from https://www.kareo.com/blog/article/10-questions-ask-hiring-medical-billing-service 

For services provided using telemedicine (real-time, interactive, audio and visual) between Jan. 27, 2020 (the day the public health emergency was declared) and June 30, 2020, CMS says to add modifier 95, synchronous telemedicine services rendered via real-time interactive audio and visual video telecommunication system, on the claim.

For services going forward via telehealth, until June 3, 2020, use modifier 95.
For telehealth services performed starting July 1, 2020 until the end of the public health emergency use HCPCS code G2025 to identify services that were furnished via Tele health in an RHC or an FQHC these claims will be paid at the $92 rate.

• The visit must use real-time, interactive, audio and visual telecommunication systems
• Practitioners can furnish these services from any location, including home

Although CMS says practitioners can also bill on-line digital E/M codes, 99421—99423 and virtual communication code G2012 and G2010, these are reported with HCPCS code G0071. G0071 will be paid at $24.76 beginning March 1, an increase from the prior rate of $13.53.
MACs will automatically reprocess claims with G0071 for claims processed after March 1. The new rate is a blended rate, based on the payment rates of 99421—99423, and the two HCPCS codes for virtual communication, G2012 and G2010. 

Credit: Coding Intel @ www.codingintel.com