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Fetal monitoring methods determine documentation and coding requirements

JustCoding News: Outpatient, May 27, 2015

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By Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC
Fetal monitoring involves the use of an electronic fetal heart rate monitor to record a baby's heart rate. Physicians most commonly perform fetal monitoring late in pregnancy and/or continuously during the intrapartum labor process to ensure a normal delivery of a healthy baby.
The CPT® Manual includes two codes for reporting fetal monitoring during labor by consulting physician (i.e., non-attending physician). The only difference is whether the physician provided supervision and interpretation (59050) or only interpreted the monitoring (59051).
Fetal monitoring can be done either externally or internally within the uterine cavity. External fetal monitoring is done via a fetal non-stress test, and is non-invasive.
Internal fetal monitoring is done via fetal scalp electrodes (FSE) and intrauterine pressure catheters (IUPC). Physicians perform internal fetal monitoring primarily during labor. However, both internal and external monitoring have been used in some circumstances during labor.
Using IUPCs
Physicians commonly use IUPC during labor and the induction of labor. The IUPC measures and denotes frequency, duration, and strength of the contractions and if the patient requires additional medications such as oxytocin or pitocin to augment labor and move it along.
The IUPC is a small, flexible tube that the physician inserts into the uterus, to lie between the baby and the uterine wall. This device provides exact measurements of the contractions, unlike external monitors, or a fetal non-stress test that only monitors the fetus.
The IUPC is primarily used when labor is progressing slowly or stalling, or if the physician notices an irregular or abnormal contraction pattern. The IUPC also enables the provider to determine that the uterine contraction process is strong enough, but not too strong, to ensure a smooth delivery for the fetus and the mother.
In addition, the physician typically leaves an IUPC left in place for the duration of the labor. Once the physician inserts the IUPC into the uterus, and verifies that it is functioning correctly, the physician then attaches it to the patient’s leg to secure it.
An IUPC’s measurements are not affected by maternal movement and can also be used with FSEs or other internal fetal monitoring devices during labor.  
Using FSEs
Coders can also report FSE placement with codes 59050 and 59051 or they can use unlisted procedure code 59899 (unlisted procedure, maternity care and delivery). An FSE is also bundled into the normal global delivery process.  
However, if the request of FSE placement by the attending delivery physician is substantiated in the chart, and the consulting provider inserts the FSE and oversees monitoring of the fetus, the consulting provider can code for the placement, interpretation, and monitoring function of the FSE.
Codes 59050 and 59051 include some very important verbiage to indicate that a “consulting physician” must perform this monitoring. This means that if an attending provider is performing the entire intrapartum delivery and uses an IUPC or FSE, then it is bundled with the delivery itself.
However, if the intrapartum attending provider calls in a specialist to perform or consult on the fetal monitoring, these codes become billable/codeable for the “consulting physician.” Note that codes 59050 and 59051 do not specifically state the use of only an IUPC or FSE, but simply “fetal monitoring.” However, these are currently the most commonly used methods of fetal monitoring.
Coding and documentation considerations
When reporting codes for the consulting physician, coders should look to capture all applicable codes. In addition to the fetal monitoring, the actual consultation evaluation and management can also be billed.
As with any consultation, you need to determine if your payers will pay with a consultation code or if they require a hospital-based subsequent outpatient or inpatient code. If the consulting provider also performs and interprets a fetal non-stress test, that interpretation service should be coded to capture the consultant physician’s work for the non-stress test. This would be reported with code 59025 (fetal non-stress test) with modifier -26 (professional component) appended.
Documentation for the FSE and IUPC require the consulting physician to have separately identifiable documentation noting the request of his or her expertise by the attending physician.
Documentation must include whether the consultant physician is only providing the initial consultation or if he or she will continue the supervision of the IUPC and that portion of the labor process. Remember, when an IUPC is used during labor, the intent is to measure the exact forces of the contractions and make medical decisions based upon those findings.
This is the difference when determining if to bill code 59050, which includes the written documentation, supervision, and interpretation of findings. If the consulting physician will not perform the supervision, coders should report 59051.
Using IUPCs
IUPCs provide a direct measurement of the intrauterine pressure in mmHg, as well as the frequency and duration of contractions.
Ranges include:
  • Mild: 15-30 mmHg above resting tone
  • Moderate: 30-50 mmHg above resting tone
  • Strong: 50-75 mmHg above resting tone
The normal resting tone is 5-15 mmHg
The provider should verify IUPC readings using uterine palpation as needed.
Physicians may use IUPC monitoring:
  • When external methods do not provide accurate monitoring, such as in the case of maternal obesity or frequent changing of maternal position
  • To improve the interpretation of the timing of fetal heart rate decelerations in relation to uterine contractions
  • To determine the strength of contractions in cases of suspected labor dystocia or during labor induction or augmentation
In the event of a multiple gestation, the provider should use a monitor capable of simultaneously recording more than one fetal heart rate. In addition, the physician’s documentation should note and be separately identifiable of each fetus’ information.
The provider may need to perform abdominal palpation or additional for placement of the IUPC monitors, or to ensure that each fetus is simultaneously monitored.
An internal scalp electrode may facilitate monitoring once membranes are ruptured.
Using FSEs
For the application of a FSE, documentation should include:  
  • General appearance of patient and vital signs noted, including maternal temperature
  • An abdomen exam, including:
    • Appearance
    • Tenderness
    • Uterine contractions denoting intensity, frequency, and relaxation between contractions
  • Fetal heart tones: baseline, variability, accelerations, decelerations (depth, length, alignment to contractions) 
  • Notation of cervical dilatation/effacement/station
  • Confirmation of fetal vertex presentation
The FSE is applied to the scalp avoiding the fontanelles or suture lines to minimize scalp trauma
All documentation is recorded with date, time, and in-depth procedure notes in the patients’ medical record/obstetric notes. 
As the coder, if you do not see this information in the documentation, query the provider.
Case scenario
Review the scenario below, which includes documentation for IUPC placement and the procedure and ICD-9-CM and ICD-10-CM codes that should be reported.
I was called by the attending midwife to review the fetal strip for her patient who is in labor currently at 41 3/7ths weeks. Upon my review of the strip, fetal monitoring was still showing variable fetal heart rate decelerations and hard to define uterine contractions that are not picking up on the monitor correctly. Patient is gravida 2, para 1 at 41 and 3/7 weeks with spontaneous rupture of membrane, 75% effaced and 2.5 cm dilated. Patient had been laboring for the last four hours with no apparent progress and the appearance of incoordinate contractions at this time.
Patient's abdomen is gravid, patient is obese. Patient appears pale but temperature is normal at 98.3, all vitals are stable. Previous strip shows occasions of incoordinate contractions. I discussed the IUPC catheter with the patient and her midwife. Patient would like to proceed with IUPC. I obtained consent from patient for the IUPC catheter to be placed.
IUPC placed to monitor contractions and to allow for amnioinfusion for variables if needed. Catheter was placed as per protocol, and EX C/7/0. Good acceleration noted at the time of IUPC placement. I have been asked to continue to monitor the patient and oversee the fetal responses in coordination with midwife and global MD. Total time spent with patient was 15 minutes.
Initial IUPC readings:  at 12:29 p.m. after three contractions, during peak contractions, I calculated 300 MVUs with a resting tone of 15 mmHG, which appears to show that the patient has moved into a stabilized contraction pattern. I will oversee and coordinate care with midwife.
Coders should report CPT code 59050 along with one of the following visit codes:
  • 99251-25 (inpatient consultation for a new or established patient) with modifier -25 (significant E/M services on the same date as another procedure)
  • 99231-25 (subsequent hospital care, per day, for the evaluation and management of a new or established patient) with modifier -25.
ICD-9-CM codes:  
  • 659.73, abnormality in fetal heart rate and rhythm complicating labor and delivery
  • 661.43, hypertonic, incoordinate, and prolonged uterine contractions
  • 645.13, post-term pregnancy
ICD-10-CM codes:
  • O76, abnormality in fetal heart rate and rhythm complicating labor and delivery
  • O62.4, hypertonic, incoordinate, and prolonged uterine contractions
  • O48.0, post-term pregnancy
In the scenario above, the patient's global care is being provided by the attending certified nurse midwife. The midwife then requested the physician’s expertise in the form of a consultation and ultimate care and oversight of the fetal monitoring. The IUPC interpretation is well documented, in addition to the documentation for the consultation or E/M of the patient.  
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, and ICD-10-CM/PCS trainer is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog: http://lori-lynnescodingcoachblog.blogspot.com.



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