Transkrip lengkap untuk Labor Management & Delivery (June 16 recording of Town Hall series)

criteria is considered complex. 00:04:48.720 --> 00:04:54.800 Now, going into delivery care, these delivery codes will look a little bit familiar, but they are new codes. 00:04:56.399 --> 00:05:11.040 Delivery begins when labor is complete or when the presenting part of the fetus is visible and firmly rimmed by the vaginal introitus for vaginal deliveries, interrupted or when the decision is made for cesarean delivery after labor, or avoided when a cesarean delivery has been scheduled. 00:05:11.279 --> 00:05:23.759 A vaginal delivery should be coded as 59431, feedback as 49532, primary cesarean is 59502, and repeat cesarean is 59503. 00:05:26.240 --> 00:05:33.439 Vaginal delivery services include the delivery of the placenta and the work of repairing a first or second degree epicionomy or laceration. 00:05:33.600 --> 00:05:39.920 If a vaginal delivery is attempted but results in a cesarean delivery, report the appropriate delivery code only. 00:05:47.519 --> 00:06:00.160 A vaginal delivery with or without epicionomy should be coded as 59431, and a vaginal delivery with or without epicedionomy and after a previous cesarean delivery should be coded as 59432. 00:06:03.199 --> 00:06:10.480 A primary cesarean delivery is reported for a patient who has not previously had a cesarean, which would be code 59502. 00:06:10.639 --> 00:06:21.600 A repeat cesarean delivery is reported for a patient who has previously had a cesarean delivery, including one who undergoes labor management, resulting in a repeat cesarean delivery, and would be coded as 59503. 00:06:22.000 --> 00:06:26.800 For cesarean delivery for multiple gestations, report only one cesarean delivery code. 00:06:29.120 --> 00:06:35.199 A hysterectomy after cesarean may be reported by the same or different physician performing the cesarean delivery. 00:06:35.360 --> 00:06:39.279 Do not use 59623 for pharmacological management of hemorrhage. 00:06:40.079 --> 00:06:45.199 There are other codes new to delivery in postpartum that will be discussed at our town hall on June 30th. 00:06:45.600 --> 00:06:48.879 With that, let's turn over to our experts for questions. 00:06:56.879 --> 00:07:00.480 Is an admission built on the same claim as labor management? 00:07:02.399 --> 00:07:02.879 Thank you. 00:07:03.040 --> 00:07:05.680 And first I just want to thank everyone for joining. 00:07:05.759 --> 00:07:10.319 I really appreciate your time and your interest in wanting to learn about the new code set. 00:07:10.959 --> 00:07:21.600 So when we do an admission and we're looking at specific claims, the new labor management codes include that initial labor management code for that first day. 00:07:21.839 --> 00:07:34.160 This code was written to describe the work of reviewing a patient's clinical course, taking a history, physical, and the process of the admission, as well as the labor management on that initial day. 00:07:34.319 --> 00:07:41.519 So you would select the appropriate initial complexity, and then whether it is straightforward or complex. 00:07:41.680 --> 00:07:48.079 And all codes from that site's admission or that complete encounter would be included together on that same plane. 00:07:50.000 --> 00:07:50.319 Great. 00:07:50.480 --> 00:07:51.040 Thanks, Dr. 00:07:51.199 --> 00:07:51.759 Martin. 00:07:52.000 --> 00:07:52.319 Dr. 00:07:52.480 --> 00:07:59.600 Leggett, does billing for a delivery cover the entire hospital admission, or should each day of the admission be billed separately? 00:08:00.399 --> 00:08:01.680 That's a great question. 00:08:01.759 --> 00:08:06.160 And it highlights one of the big changes that are coming with this new code set. 00:08:06.399 --> 00:08:11.600 So with our new code set, each day of admission should be coded for and billed separately. 00:08:11.920 --> 00:08:17.120 And I actually really like this approach to LNG billing because it just makes sense. 00:08:17.279 --> 00:08:29.759 So in the previous system, a patient who came in in active labor and delivered the same day was considered the same amount of work, meaning the same amount of RBUs as a three-day long induction of labor. 00:08:29.920 --> 00:08:40.960 And those are such distinct scenarios that require vastly different amounts of work when we compare a single day of management versus multiple days of patient care. 00:08:41.120 --> 00:08:51.279 And so now moving forward, we are going to have codes that reflect the uniqueness of each person's labor course and reflect the work that we're putting in each day for our patients. 00:08:53.120 --> 00:08:53.600 Great. 00:08:53.759 --> 00:08:54.559 Thank you. 00:08:55.120 --> 00:08:55.440 Dr. 00:08:55.600 --> 00:09:00.960 Horton, how should billing be handled when admitting HP and delivery occur on the same day? 00:09:01.120 --> 00:09:04.720 And uh especially if this is the patient's first ever encounter. 00:09:06.080 --> 00:09:06.879 Good question. 00:09:07.120 --> 00:09:15.039 And it is important to remember and consider that new versus established is really only significant for outpatient coding. 00:09:15.200 --> 00:09:27.759 From this scenario, we'd follow the same rules as above as we discussed with admission using an initial labor management code, either straightforward or complex, and then you would add the fitting delivery code for that day. 00:09:28.000 --> 00:09:36.720 So if someone is admitted on the same day they labor and they deliver, then you'd have two codes for that for adding for that calendar day. 00:09:36.960 --> 00:09:44.639 I do want to take the opportunity though to talk through some of the common admission scenarios because they would be, they could be treated differently. 00:09:44.799 --> 00:09:50.080 We just talked about the initial labor management when you're admitting a patient for labor and delivery. 00:09:50.399 --> 00:10:08.960 For anti-partum admissions, when you don't have the intent to labor immediately labor and deliver, you would use an initial hospital management code, and

you should use that then subsequent hospital management codes for as long as they are in the hospital without the intent to labor and delivery. 00:10:09.279 --> 00:10:17.919 Also, for the C-section codes, they are handled slightly differently depending on the repeat versus the primary if they are scheduled. 00:10:18.000 --> 00:10:20.960 So a typical repeat C-section are scheduled. 00:10:21.120 --> 00:10:25.840 So the work of that admission and that HMP is included in that code. 00:10:26.080 --> 00:10:33.279 So for repeat C-sections that are scheduled, you would only code for that one repeat C-section code. 00:10:33.519 --> 00:10:38.960 Because typically primary C-sections happen after they've attempted a labor and delivery. 00:10:39.200 --> 00:10:44.080 The work of an HMP isn't baked into that primary C-section code. 00:10:44.240 --> 00:10:48.559 That was part of the initial labor management when they were initially admitted. 00:10:48.720 --> 00:11:00.320 And so if you have a scheduled primary C-section, you would also code an initial hospital HMP code for that day that they are admitted. 00:11:00.480 --> 00:11:08.720 And so, in summary, if you admit for labor and delivery, use an initial labor management code, the 59080 or 81. 00:11:08.879 --> 00:11:16.159 If you're admitting for an antipartum, use the initial hospital management codes that you would use for any regular hospital admin. 00:11:16.399 --> 00:11:25.840 If you're admitting a scheduled repeat section, you use the single code just for the procedure for that repeat C-section, 5950503. 00:11:26.159 --> 00:11:38.080 However, if you're admitting a scheduled primary C-section, you would use both the 59502, the procedure code, plus you would also code for the initial hospital management. 00:11:40.159 --> 00:11:40.720 Perfect. 00:11:40.879 --> 00:11:41.679 Thank you so much. 00:11:41.840 --> 00:11:43.039 Um I'll pass it back to Dr. 00:11:43.200 --> 00:11:43.840 Leggett. 00:11:44.000 --> 00:11:53.440 Um, could you give us an example of labor starting one day and then carrying over to the next day before delivering and walk us through how to build um a typical L and D stay? 00:11:55.759 --> 00:11:57.519 Yeah, I'd be happy to do that. 00:11:57.600 --> 00:12:05.200 And I think that because this represents such a big change, um, really kind of mapping it out might help people. 00:12:05.600 --> 00:12:09.919 Um, so I want to stick with the example I used before. 00:12:10.080 --> 00:12:15.919 So we have, you know, in scenario one, we have an active labor patient who delivers really quickly. 00:12:16.159 --> 00:12:19.600 And then we're gonna compare that to a multi-day induction. 00:12:19.919 --> 00:12:25.679 So scenario one, you have a healthy patient, she comes in and active labor, you admit them. 00:12:25.919 --> 00:12:29.600 And that represents your initial day of straightforward care. 00:12:29.840 --> 00:12:35.440 So for initial straightforward care, our new code is 59080. 00:12:35.840 --> 00:12:43.840 And I know we don't all have these memorized yet, but I'm gonna say them throughout so that hopefully by the end of this town hall, some of the numbers are sticking. 00:12:44.480 --> 00:12:51.519 And you know, as Horton has already said, you're only going to use one labor management code per calendar day. 00:12:51.679 --> 00:12:57.679 And so when you meet the patient, that's your initial day, and that's the one code that you'll use for labor management. 00:12:58.559 --> 00:13:13.279 Um, your labor management code includes your face-to-face time with the patient, it includes your exam, any ordering of tests, interpreting labs, making a plan, anything really you do to manage labor during that calendar day is reflected by that code. 00:13:13.840 --> 00:13:17.200 And let's say that patient delivers vaginally the same day. 00:13:17.519 --> 00:13:24.960 So for your billing, you're gonna do in addition to the 59080, you're also gonna bill for vaginal delivery. 00:13:25.039 --> 00:13:27.840 And the code for that is 59431. 00:13:28.159 --> 00:13:34.639 And that is for vaginal delivery, and it includes delivery of the placenta and repair of a first or second degree lak. 00:13:34.879 --> 00:13:37.759 But let's complicate the scenario a little bit, right? 00:13:37.919 --> 00:13:41.120 I said active patient, she delivers, she was healthy. 00:13:41.279 --> 00:13:44.159 Um, but let's say she has a third-degree laceration. 00:13:44.879 --> 00:13:56.480 And so, in addition to your vaginal delivery code and your initial labor management code, you're also gonna bill for the repair of the third degree laceration, which is code 59433. 00:13:56.960 --> 00:14:01.679 So that's a one and done, like all everything happened in one day scenario. 00:14:02.159 --> 00:14:07.120 I'm gonna pivot now to talk about the multi-day course and what that would look like. 00:14:07.360 --> 00:14:10.159 So in the next scenario, we admit a patient. 00:14:10.320 --> 00:14:16.240 Let's say she's 34 weeks, she has severe preecalampsia, and you're admitting for an induction of labor. 00:14:16.480 --> 00:14:19.039 A patient like this would be considered complex. 00:14:19.200 --> 00:14:24.159 Um, so on the day of admission, we would code for an initial day with complex medical care. 00:14:24.240 --> 00:14:27.120 So that's code 59081. 00:14:27.919 --> 00:14:31.440 And this complicated patient has a really long induction course. 00:14:31.519 --> 00:14:32.399 It takes three days. 00:14:32.480 --> 00:14:34.480 So day one is your initial labor day. 00:14:34.799 --> 00:14:38.000 Day two, you would bill 59083. 00:14:38.399 --> 00:14:43.120 That's the code for subsequent management of complex labor. 00:14:43.600 --> 00:14:46.320 And then on day three, the patient delivers vaginally. 00:14:46.480 --> 00:14:49.120 So day three, you need another labor management code. 00:14:49.200 --> 00:14:55.600 So five nine zero eight three to capture the complex labor management, and you would code for the

delivery itself. 00:14:55.759 --> 00:15:00.960 And in this pretend example, it's an uncomplicated vaginal delivery with a first-degree lack. 00:15:01.120 --> 00:15:06.480 So you're gonna code 59431, which is just our code for vaginal delivery. 00:15:08.960 --> 00:15:09.600 Perfect. 00:15:09.759 --> 00:15:10.799 Thank you so much. 00:15:10.960 --> 00:15:11.679 Um, Dr. 00:15:11.840 --> 00:15:18.639 Horton, let's say that a patient is being admitted for induction of labor and the labor continues for a while without making progress. 00:15:18.720 --> 00:15:23.039 Um, the doctor and patient decide to send them home and try again on another day. 00:15:23.200 --> 00:15:25.200 How should we build this visit to the hospital? 00:15:25.279 --> 00:15:32.480 And would that still be billed under labor management or a regular inpatient hospital visit 99221-99233? 00:15:33.840 --> 00:15:34.480 Understand. 00:15:34.559 --> 00:15:43.679 And I think when you consider, always think about what was your intention when you were admitting the patient and what work went into while you were with the patient. 00:15:43.919 --> 00:15:48.879 And so there is benefit also too that we will be coding in hindsight. 00:15:48.960 --> 00:15:55.279 So you get to look back upon what you've done during those days and the calendar day in the episode. 00:15:55.440 --> 00:16:02.320 And so if your goal is to admit a patient for labor and delivery, then you code for the initial labor management. 00:16:02.480 --> 00:16:12.720 That's going to include all of the history physical and the process of admission, plus that initial day of the managing the labor, the patient that you've worked with through that first day. 00:16:12.960 --> 00:16:20.080 If say you get to a second day, as Cecilia has commented, you would be coding a subsequent labor management day. 00:16:20.240 --> 00:16:28.799 Now, say you get partway through that day and things just aren't moving, and you make the decision with the patient that chose to go home. 00:16:29.120 --> 00:16:33.679 So in these codes are not built into the work of discharge. 00:16:33.759 --> 00:16:42.240 And so if you're going to discharge a patient, now on the labor management day, you would code a lay a discharge code with that. 00:16:42.480 --> 00:16:53.440 Now it is important to know that the CPT codes, if someone delivers, that delivery code includes the immediate postpartum care and period. 00:16:53.759 --> 00:17:03.679 And so if someone labors and delivers and then goes home, that same calendar day, you would not code a discharge code. 00:17:03.759 --> 00:17:07.680 It's explicitly kind of discussed in the NCPT codebook. 00:17:07.920 --> 00:17:15.200 But if they haven't delivered and you're doing labor management, you would code a discharge code for the time that they go home. 00:17:15.440 --> 00:17:18.319 Now, when the patient returns, you start over. 00:17:18.400 --> 00:17:21.839 And so on a hopefully that is a different calendar date. 00:17:22.000 -->

00:17:22.960 And they come back. 00:17:23.039 --> 00:17:28.400 And if it is a calendar date, you would start with an initial labor management code. 00:17:29.119 --> 00:17:36.079 Yeah, I would just add, I think that as we start using these new codes, more and more scenarios will come up. 00:17:36.160 --> 00:17:41.759 So, Horton, you just gave the example of you know a patient who labors for a few days and then leaves and comes back. 00:17:41.839 --> 00:17:44.799 And um and we've all experienced that. 00:17:44.880 --> 00:17:49.839 And I think there'll be different permutations and different uh presentations that we all encounter. 00:17:49.920 --> 00:18:06.400 And for me, one of my big takeaways is I think documenting our intent and documenting the clinical scenarios is gonna be really important because we're gonna need to all of us are gonna need to learn how to apply these codes for pretty unique situations. 00:18:06.559 --> 00:18:08.559 You know, I would say no labor course. 00:18:08.640 --> 00:18:12.720 Uh, they they all bring new joys and surprises for us, you know. 00:18:12.960 --> 00:18:18.079 Um, so I think that documentation will be really important as we're still learning these codes. 00:18:18.799 --> 00:18:19.839 Yeah, I I agree. 00:18:20.000 --> 00:18:37.200 I also think it's gonna be really important for us, and we're gonna I think we're gonna talk about some of this later, is that we're individually also working with our payers to understand what that relationship is, that these are new codes, and we're gonna learn how to use these once they go live and we start using them come next January. 00:18:39.279 --> 00:18:39.680 Great. 00:18:39.839 --> 00:18:40.640 Thank you both. 00:18:41.039 --> 00:18:41.599 Um, Dr. 00:18:41.759 --> 00:18:46.640 Leggett, do you bill labor management if the patient is in the emergency department? 00:18:48.799 --> 00:18:49.759 That's a great question. 00:18:49.920 --> 00:18:58.000 It's a tough question because it really depends on how your practice is set up and how your hospital system is set up. 00:18:58.160 --> 00:19:01.440 So there are a lot of there are a lot of different factors at play here. 00:19:01.680 --> 00:19:09.920 So specifically, billing related to care in the ED is going to depend on your practice structure and then whether or not you actually admit the patient. 00:19:10.160 --> 00:19:12.160 Um, let me give you a couple examples. 00:19:12.400 --> 00:19:20.319 So if you see and evaluate a patient without admitting them and the patient's released home, that's pretty simple. 00:19:20.480 --> 00:19:27.519 You would use you would bill using the appropriate EM code for your service for any type of ED encounter. 00:19:27.839 --> 00:19:43.599 Um, if the patient is seen in the ED by someone who's not in your recovering group, and then that that provider would bill using the emergency medicine or outpatient codes, and they'd use a 25 modifier to indicate that this is a significant separate care. 00:19:44.160 --> 00:19:52.720 And then you and your team would use the labor management codes for your part of the encounter, meaning your initial labor management code. 00:19:52.880 --> 00:20:03.839 Um, so just depending on what type of providers are involved in the care and whether or not those providers were on the same team or not is going to dictate how you code for this. 00:20:04.160 --> 00:20:11.039 Um a scenario where this might occur would be if you have a separate OB emergency space at your facility. 00:20:11.200 --> 00:20:15.759 That's an example when this kind of more complicated coding may be at play. 00:20:16.319 --> 00:20:25.680 And then if a patient is seen by someone in the ED and is admitted by someone who are both part of the same covering practice, then that's simple and clear. 00:20:25.839 --> 00:20:29.440 That's a single code for admission is used at that time. 00:20:29.680 --> 00:20:34.000 And so I don't have like a simple answer that will apply to everyone. 00:20:34.160 --> 00:20:39.359 It's really gonna depend on how you practice and your specific environment. 00:20:42.160 --> 00:20:43.039 Uh back to Dr. 00:20:43.200 --> 00:20:51.200 Horton, how do the new codes account for variation in labor management approaches across institutions, particularly in high-risk populations? 00:20:52.559 --> 00:21:04.400 Yeah, because it is true that depending on where you are, it may you may be in a large urban andor academic setting, you may be in a smaller community hospital. 00:21:04.640 --> 00:21:11.759 The codes do allow for change in complexity over time for the admission, and that is something to be really mindful of. 00:21:12.000 --> 00:21:15.680 And a pathway for considering transfer is there. 00:21:15.839 --> 00:21:23.279 And this is whether you're transferring from one facility to another or you're escalating to a different team. 00:21:23.440 --> 00:21:37.599 Now, it is really important that if you're to maintain to be able to code for what you're you're doing or what someone else is doing, similar to what Cecilia had commented on, it's important to know who is a part of the covering group. 00:21:38.079 --> 00:21:52.960 If you send a patient from one facility to another that's very, very cut and dry, the facility for the first time will previously, so currently, right now, with the globals, they may lose this sort of energy in what they have done. 00:21:53.039 --> 00:21:59.759 And so with the new codes, they'll be able to code the amount of the initial labor management or subsequent labor management. 00:22:00.319 --> 00:22:02.000 That occurred at that facility. 00:22:02.160 --> 00:22:13.519 And when the patient arrives at the new facility, that team would be able to code a new and initial labor management and then carry on as if they've taken in the new patient. 00:22:13.759 --> 00:22:18.240 That's also true if you're escalating to a non-covering group team. 00:22:18.400 --> 00:22:25.599 An example of this might be shifting to a

maternal phenal medicine group team that's not a part of your covering group. 00:22:25.839 --> 00:22:31.200 Then the labor management that you have performed, you would code for your labor management. 00:22:31.279 --> 00:22:40.079 And when they do their initial assessment and you're for the totally new group taking on the care, they would use an initial labor management code. 00:22:40.400 --> 00:22:45.599 You may have a patient that also has an emission that changes over time. 00:22:45.759 --> 00:22:53.119 And so that emission that may be straightforward on that first day may change throughout even that day. 00:22:53.200 --> 00:22:59.759 And that calendar day, it's important to look at what was the highest level of complexity that occurred on that day. 00:22:59.920 --> 00:23:04.799 You would code the highest complexity documented on that calendar date. 00:23:05.039 --> 00:23:07.440 The same is true across labor days. 00:23:07.680 --> 00:23:19.920 You may have a patient that was admitted as a straightforward initial labor management, but then on day two, as you're managing, say as an example, she develops pre-eclampsia. 00:23:20.240 --> 00:23:27.359 And so she now has a condition that pulls her out of that straightforward list into that complex. 00:23:27.599 --> 00:23:34.079 And so for that second day, it may be subsequent complex labor management. 00:23:34.240 --> 00:23:41.519 And so the two codes don't uh may not reflect the same care because different care may be given on different days. 00:23:41.759 --> 00:23:50.240 And so as people are developed, just be mindful of what you're seeing, who the patient, what the work you're doing is, and what you are documenting. 00:23:50.480 --> 00:23:59.519 If a patient needs to be transferred, know that there are codes and there is a pathway for managing that from both sides from receiving teams. 00:24:00.480 --> 00:24:02.799 Yeah, I'd like to add before we move on. 00:24:02.960 --> 00:24:07.599 So, of course, you know, in one scenario, Horton was talking about transferring care, right? 00:24:07.680 --> 00:24:09.039 Or escalating care. 00:24:09.359 --> 00:24:21.519 But I I also want to flag, and like Horton was talking about this just a moment ago, that your level of complexity can change even if you don't change who the providers are, right? 00:24:21.759 --> 00:24:24.480 Um simple labor can become complicated really fast. 00:24:24.640 --> 00:24:27.519 We don't always escalate and transfer to a different facility. 00:24:27.680 --> 00:24:29.839 You don't always get other providers involved. 00:24:30.000 --> 00:24:39.759 And um, I think something that'll be very important for us is to remember that our code selection should represent the highest level of complexity on that day. 00:24:39.920 --> 00:24:48.880 Um and I think that'll be something that as we do change of shift, we'll need to be mindful of that we share with the oncoming provider. 00:24:48.960 --> 00:24:52.160 Um, if we've had a change in complexity, that should be noted. 00:24:52.319 --> 00:25:11.440 And um something that comes to mind for me is being careful when we, if you copy forward a note, you know, if the note from your previous uh teammate on the shift comments about simple or uncomplicated labor, but you inherited a very different clinical scenario, you need to make sure that your note reflects that change. 00:25:13.839 --> 00:25:14.319 Awesome. 00:25:14.640 --> 00:25:15.680 Thank you both again. 00:25:16.400 --> 00:25:16.960 Um, Dr. 00:25:17.119 --> 00:25:26.640 Leggett, does intrapartum decision-making complexity, such as trial of labor after cesarean or multiple fetal monitoring interventions, affect coding levels? 00:25:27.599 --> 00:25:31.839 That question's actually a perfect segue from the discussion we were just having. 00:25:32.079 --> 00:25:37.119 Um, decision-making complexity absolutely affects coding levels in the new system. 00:25:37.200 --> 00:25:50.960 And this is um an aspect of the new system that I am really excited about because I think that it is a better reflection of what our field really looks like and how fast things can change in labor management. 00:25:51.200 --> 00:25:58.079 Um, so in terms of complexity, for care to be considered straightforward, we have a very clear definition. 00:25:58.400 --> 00:26:08.480 It must be singleton, cephalic, normal progression of labor, routine induction or augmentation techniques, stable medical conditions, no prior history of cesarean. 00:26:08.720 --> 00:26:13.279 Um, like it's very well mapped out what straightforward care means. 00:26:13.440 --> 00:26:22.640 And I think, you know, I think all anyone in OB can clearly define a category one fetal heart rate tracing and a category three heart rate tracing. 00:26:22.720 --> 00:26:25.359 And we all know category two is really everything else. 00:26:25.759 --> 00:26:27.039 The same principle here. 00:26:27.200 --> 00:26:33.279 Straightforward care has a very clear definition, and complex care is everything else. 00:26:33.359 --> 00:26:37.920 So if you don't fit the criteria for straightforward care, then it's not straightforward. 00:26:38.079 --> 00:26:40.880 Um, and you should document accordingly. 00:26:41.119 --> 00:26:49.440 So again, straightforward care is singleton, cephalic, normal progression of labor, stable medical conditions, no priority section. 00:26:49.519 --> 00:26:53.839 And if your scenario doesn't fall into that bucket, then it's complex. 00:26:53.920 --> 00:27:05.279 And you should your note should reflect that so that anyone reading the note, whether that be uh someone on your care team or a payer, it should be very clear to them whether or not something is straightforward and or complex. 00:27:06.720 --> 00:27:14.160 And Cecilia, I would can add to because one of the things that you mentioned was routine labor induction or augmentation. 00:27:14.400 --> 00:27:15.759 So what does that mean? 00:27:16.000 --> 00:27:26.960 And so you we want to

take into account the complex, the medical complexity of the patient themselves when you're really considering the complexity of the codes uh themselves from straightforward versus complex. 00:27:27.119 --> 00:27:34.240 So in this case, a routine induction may be standard um the standard uh medications that you're using. 00:27:34.319 --> 00:27:44.079 And so that may include augmentation of labor with pitocin, it may include a um cervical ripening agent or a device of some kind. 00:27:44.240 --> 00:28:02.079 And so if you have a patient coming in, the induction itself by giving semipitocin, by using cytotech or mesoprostol, or dynoprostol, cervadil, or a cervical ripening balloon, the active induction itself doesn't increase the complexity of the patient. 00:28:02.160 --> 00:28:12.480 Um, in and of itself, it's the medical care and the complexity of their conditions and the work going into that that will really change the complexity codes. 00:28:14.240 --> 00:28:14.559 Perfect. 00:28:14.799 --> 00:28:16.960 Yeah, I'll add to that, Horton, if it's okay. 00:28:17.119 --> 00:28:27.359 You know, with our coding, um, our documentation is going to be so important for specifically supporting like something like an induction of labor. 00:28:27.440 --> 00:28:34.079 And like as you mentioned, just because it's an induction that requires multiple medications doesn't necessarily mean it's complex, right? 00:28:34.160 --> 00:28:36.160 If things are progressing normally. 00:28:36.400 --> 00:28:57.920 Um, and so your documentation, for example, let's say that induction then falls off a normal labor course, and now you're dealing with protracted labor and you're dealing with labor infections and um a concerning strip, like all of these types of as we deviate away from normal, that's when things start to be considered complex for the sake of billing. 00:28:58.079 --> 00:29:05.759 But yeah, something taking a long time and requiring multiple medications doesn't necessarily make it clinically complex or complex for the sake of billing. 00:29:05.839 --> 00:29:12.480 And it's really that whole clinical picture that's really important to paint in our documentation so people can understand. 00:29:13.359 --> 00:29:14.880 Yeah, I totally agree. 00:29:15.039 --> 00:29:26.720 And it will one of the things we're gonna have to really kind of wrap our minds around because many of us do labor notes, many of us will do daily notes on patients, especially on the floor, but our documentation may have to be different. 00:29:26.880 --> 00:29:41.839 One thing that also is really important for hospitals as well, if you're delivering in uh facilities, is that you have documented the thing, the conditions that are present on our um admission, um, because that really can change uh the patient's complexity. 00:29:42.000 --> 00:30:08.079 And then reviewing, as Cecilia kind of talked about when you go to do that discharge, go through and look at what were the problems that you addressed and

make sure that you're labeling each one of them specifically in both notation and if you've got an electronic medical record system that allows you to pull in those ICD um ICD 10 codes, it will just add to the weight of the uh your evidence for whatever codes that you are choosing. 00:30:11.839 --> 00:30:12.240 Great. 00:30:12.960 --> 00:30:14.400 Uh back to Dr. 00:30:14.559 --> 00:30:15.279 Horton. 00:30:15.440 --> 00:30:21.839 What are some examples of when to use modifier 22 uh to labor management codes for both routine and complex? 00:30:22.000 --> 00:30:24.640 Is there an average time these codes should take? 00:30:24.799 --> 00:30:28.720 So if exceeded, we can build at a higher level, such as modifier 22. 00:30:29.279 --> 00:30:30.160 It's a great question. 00:30:30.240 --> 00:30:35.119 I love all the questions of like the idea of like diving into what is complex, what is straightforward. 00:30:35.279 --> 00:30:41.519 One thing I can say is that that that list is a finite list of what's straightforward. 00:30:41.599 --> 00:30:48.240 If it's not in that left-hand, and when I look at it, the left-hand column of what is straightforward, then it's complex. 00:30:48.400 --> 00:30:49.440 Everything else is complex. 00:30:49.519 --> 00:30:59.359 And so if it falls outside of the straightforward conditions, then you should definitely be documenting on a complex management code. 00:30:59.680 --> 00:31:11.599 And uh with one of the things to mention, and we've already kind of talked about it, is the length of labor itself does not specifically increase its complexity. 00:31:11.920 --> 00:31:21.920 And so unless you have specifically diagnosed prolonged labor, which luckily we have a COG practice guideline number eight, which you can refer to. 00:31:22.079 --> 00:31:26.480 It was just recently um in 2024, it was just recently um edited. 00:31:26.559 --> 00:31:37.359 And so you can go and you can look at those guidelines that have differences between uh nulliprus patients, potentially even within that how long people are pushing. 00:31:37.440 --> 00:31:42.960 And so look at prolonged, latent, prolonged active in the different phases themselves. 00:31:43.279 --> 00:31:50.640 So if you have a diagnosis like prolonged, then that can escalate this to a complex labor management. 00:31:50.799 --> 00:31:56.880 But the length itself is not does not change uh the complexity for the code itself. 00:31:57.200 --> 00:32:05.519 Now, there are a couple of times that the CPT code book does call out when to add specific, uh specifically a modifier 22. 00:32:05.680 --> 00:32:10.400 It does call out for the delivery code, it talks about um breach deliveries. 00:32:10.640 --> 00:32:20.319 You'll also notice when you look through the code, so the codes that the word uh forceps and vacuums, when it refers to the delivery itself, are no longer there with the delivery codes. 00:32:20.400 --> 00:32:28.640 And so if you have done uh more complex delivery of a valuable delivery, that may be a time to add modifier 22 as well. 00:32:28.960 --> 00:32:46.640 If you have spent considerable time and considerable energy with a patient with an exceptionally challenging medical care, you're managing multiple drips, somebody is really ill, and your document, your documentation displays that effort, then you could add a modifier 22. 00:32:46.720 --> 00:32:48.079 It may be appropriate. 00:32:48.319 --> 00:33:10.960 One really important thing, though, is to this is highlights of time that you should really be working with your coding team and your billing team and your payers to understand how they will work with these modifiers as we start to use them, what is being covered, what may not be, how does it change the payer kind of uh the payer's output um for these codes? 00:33:11.119 --> 00:33:14.559 It's incredibly important to develop these relationships. 00:33:14.640 --> 00:33:29.839 And I'm actually going to talk a little bit more about ICU level care in a little bit, but it's important to know and document what are the complexities that are that are backing up the use of the 22 modifier, which if you've not before, I should take a step back. 00:33:29.920 --> 00:33:37.599 So 22 modifiers are when you add when something is above and beyond, uh, you've put above and beyond the work of the uh that code. 00:33:37.680 --> 00:33:48.799 And so you're you're looking to signify with the modifier that you have done more work, um, work that is similar to what this code describes, but just in a greater capacity. 00:33:51.680 --> 00:33:52.319 Great. 00:33:52.559 --> 00:33:53.119 Uh Dr. 00:33:53.279 --> 00:34:02.880 Leggett, how are codes applied when labor includes multiple interventions such as induction and operative vaginal delivery and postpartum hemorrhage management? 00:34:04.799 --> 00:34:06.079 Great question. 00:34:06.640 --> 00:34:16.960 So we all know that labor and delivery can get complicated pretty quickly, um, especially in terms of like the number of procedures or interventions that we need to do. 00:34:17.199 --> 00:34:30.800 In terms of how we code for this, I think the, and I don't mean to sound like a broken record, but my biggest piece of advice is that we really need to document clearly and thoroughly so that we can rely on our notes to bill after the fact. 00:34:30.960 --> 00:34:40.559 Because frankly, if you're in a delivery that requires forceps and then ends up in the OR and then has a hemorrhage, billing is the last thing. 00:34:40.719 --> 00:34:46.639 I mean, it's not even on your mind at that point, you know, um, because you're really in an acute situation. 00:34:47.199 --> 00:34:53.119 Um and so, you know, we're able to bill after the fact as we should be. 00:34:53.360 --> 00:35:06.159 But um, as we're learning these new codes, I think that documenting anything that we did and what happened in these complex clinical scenarios will really help us because we can let it marinate later, right? 00:35:06.320

--> 00:35:15.360 After the acuity is settled down, we can review our notes and think about which codes would apply um most appropriately given everything that happened. 00:35:16.000 --> 00:35:31.039 Um and so I think that like being able to rely on our documentation will help us all as we transition and also help our billers and coders, like on our administrative teams, and also help our payers because it's a new world for all of us. 00:35:31.280 --> 00:35:41.679 Um in terms of you know, how would you code for someone who has a complicated delivery and has is complicated via postpartum hemorrhage? 00:35:42.000 --> 00:35:44.000 Um, so let's start with the labor portion. 00:35:44.159 --> 00:35:52.800 As we've mentioned throughout, you know, maybe the labor was uncomplicated and things only got, you know, uh complicated during the delivery. 00:35:52.960 --> 00:36:00.719 So in that case, you'd use your 59082 code um for your labor day of care. 00:36:00.880 --> 00:36:10.800 And then once it became complicated, meaning it no longer fit that criteria of straightforward that we talked about earlier, then you would shift to your 59083 codes. 00:36:11.119 --> 00:36:20.239 But the delivery, um, if it's a vaginal delivery, even if you end up needing like forceps or vacuum, you're still going to use a vaginal delivery code for that. 00:36:20.880 --> 00:36:26.480 Um, and some new codes for us to keep in mind is for complications like a postpartum hemorrhage. 00:36:26.880 --> 00:36:36.159 We have new code for procedures for uterine tamponade, whether that's done with a vacuum or suction device or a tamponade device or even packing. 00:36:36.320 --> 00:36:39.840 Um, and the code for that would be 59623. 00:36:40.159 --> 00:36:43.119 And I think that's a new code for all of us. 00:36:43.280 --> 00:36:53.519 Um and as we're learning these codes, another thing to keep in mind is that the postpartum hemorrhage code, it's really for postpartum hemorrhage procedural management, not medication management. 00:36:53.679 --> 00:37:00.719 So if you end up using multiple urotronic medications to control acne, that's not what the code is for. 00:37:00.880 --> 00:37:08.800 The code would be only for hemorrhage management that required some type of procedure, meaning tamponot or suction device or packing. 00:37:10.400 --> 00:37:23.360 This may be a time too to because we've got a nice run-up to consider for whatever systems that you're using, electronic medical record system, um, most people will be on, is look at the notes that you have. 00:37:23.440 --> 00:37:40.480 And this is the time to start working with your teams to craft standards across your team and working with your facility and your digital teams to help create that uh that uh single note or at least a standard note for your team to help with doing some of this documentation. 00:37:40.639 --> 00:37:49.360 And because we have new codes like the uterine tamponide, you could uh you make sure that you've got a procedure note just for that. 00:37:54.320 --> 00:37:56.159 Um, I'll pass it back to Dr. 00:37:56.320 --> 00:37:57.039 Horton. 00:37:57.280 --> 00:38:04.480 How should we code cases involving clinical uh escalation such as hemorrhage risk or ICU level monitoring during labor? 00:38:06.000 --> 00:38:06.639 Good question. 00:38:06.800 --> 00:38:23.199 So complexity, we have kind of built into the code system itself, looking at uh the intention if this is a patient that you have is an antipartum versus you have for um the uh for labor management. 00:38:23.440 --> 00:38:25.760 And so let's take the two different scenarios. 00:38:25.840 --> 00:38:42.400 Can we walk through the path of you've got someone laboring, you've got an escalation of care needed potentially within the same facility, you can hand off to an escalated uh sort of a different group that might have different medical background or uh care, say in the MFM group. 00:38:42.559 --> 00:38:53.840 They you can transfer to them if they're not part of the your covering group, then you would code for labor the labor management, and then they would code for also an initial labor management code as they take the patient sort of on. 00:38:54.159 --> 00:39:00.400 Now, as long as they are laboring, you would continue to code for labor management codes. 00:39:00.639 --> 00:39:13.119 It is important to know that specifically the CPT code book says that we should not be using IC um ENM codes, other ENM codes or ICU codes on the calendar date of delivery. 00:39:13.360 --> 00:39:23.920 And so for the date of the delivery itself, if you're managing labor, you would code most commonly a complex subsequent or complex initial labor management code. 00:39:24.079 --> 00:39:32.480 Now, for postpartum, it's really important that you're coding the subsequent care that you're doing. 00:39:32.800 --> 00:39:35.760 In the next town hall, we're gonna talk a little bit more about that. 00:39:36.000 --> 00:39:53.599 But for those and those days, if they are in the ICU and you are the one who's providing that primary care, they meet the criteria of an intensive care patient and you're documenting towards that, then you can code and those subsequent dates I see um the ICU care codes. 00:39:53.679 --> 00:39:59.920 It's just important to know that the ICU and other ENM codes on the date of delivery itself shouldn't be coded. 00:40:00.079 --> 00:40:01.840 Those are really with labor management. 00:40:02.000 --> 00:40:14.480 Now, if it's an anti-parton patient, so you've admitted them using hospital management codes and/or subsequent hospital day codes, and then they are escalated to uh to ICU care. 00:40:14.719 --> 00:40:31.679 Now, there is a pathway for even on the same day coding a subsequent uh hospital management into an intensive care code, or just coding if they have spent that full day as an intensive care and you've been managing them as an intensivist, utilizing the intensive care codes. 00:40:31.840 -->

00:40:38.639 Um, we are gonna learn more as we use these codes, and we encounter more and more intensive scenarios. 00:40:38.800 --> 00:40:46.639 Now, one thing kind of think about too in these antipartum patients are when you admit a patient and you're not sure they're in labor or not. 00:40:46.800 --> 00:40:56.079 And so a great example would be someone who's coming in and you're observing them for labor to see if they are going to go into labor. 00:40:56.239 --> 00:40:58.480 In this case, that's an antipartum admission. 00:40:58.639 --> 00:41:10.480 And so if you're admitting them to observation overnight, you'd use standard hospital management observation codes or inpatient admission codes, depending on the patient and what their needs may be. 00:41:10.639 --> 00:41:17.440 And then say on the next day, they define, they declare themselves and they transition into labor. 00:41:17.599 --> 00:41:23.039 Then on that day, then you uh you move to the labor management codes themselves. 00:41:23.199 --> 00:41:26.880 And so each day you think, what is the intent of this uh this admission? 00:41:27.039 --> 00:41:31.199 So the intent of this mission is are they are you going to labor and deliver them? 00:41:31.360 --> 00:41:34.880 Then that's an initial labor and man delivery management code. 00:41:35.119 --> 00:41:48.079 If you're unsure and they are an anti-partum admission, then you would use your hospital codes uh as your as your guide, and then know that you can transition as long as this isn't the next calendar date. 00:41:48.239 --> 00:41:59.920 Because one of the kind of rules to think about is in general, because we are looking back at what that what happened on those day on those days is you want to have one hospital management code per day. 00:42:00.079 --> 00:42:05.920 And so it could be a hospital management code or a labor management code, but it shouldn't be both. 00:42:08.719 --> 00:42:09.360 Perfect. 00:42:10.079 --> 00:42:11.840 Um, passing it back to Dr. 00:42:12.000 --> 00:42:19.599 Leggett, how do we handle a situation where two to three different providers manage a labor patient over a given 24-hour period? 00:42:19.679 --> 00:42:25.920 Um, so let's say a patient comes in early morning for labor and the first provider admits the patient that may be low risk. 00:42:26.239 --> 00:42:34.559 She signed out to a second doctor for daytime coverage and now develops high-risk problems like hypertension or category two FHT uh tracing. 00:42:34.639 --> 00:42:39.360 Um the third provider covers the overnight's day but delivers the patient after midnight. 00:42:39.599 --> 00:42:42.559 Who builds the labor management code in this case? 00:42:43.760 --> 00:42:54.159 I think this question is on a lot of people's minds because so many of our practicing obstetricians um do shift coverage, right? 00:42:54.239 --> 00:43:09.519 Or LD coverage, where you're having multiple providers care for patients during their labor course, and especially for patients who do have these multi-day labor courses, you're gonna have multiple providers providing care. 00:43:10.000 --> 00:43:14.159 Um so I think this is on a lot of people's minds. 00:43:14.320 --> 00:43:25.679 And you know, the short answer is that it really depends on your work environment and your setup and how you and your providers um divide up your call and coverage. 00:43:25.840 --> 00:43:30.159 Um, if your practice covers their own patients, then it's pretty simple. 00:43:30.320 --> 00:43:44.559 But if you're doing true shift work and coverage is based on time, that's where I think things are gonna get a little bit more complicated and will really depend on what works best for you and your specific coworkers. 00:43:44.719 --> 00:43:52.079 Um, I don't think there's a one size fits all approach to this uh because the way people handle LD coverage is so different, right? 00:43:52.159 --> 00:43:59.599 Like some people do every 12 hours, some people do uh a longer day shift and shorter night shift, some people split up the day across three. 00:44:00.159 --> 00:44:04.960 Providers, it's really um really does vary by practice. 00:44:05.280 --> 00:44:16.159 In terms of what should people think about, um I think each practice should really visualize this new structure in the context of how they like to cover their hospitals. 00:44:16.400 --> 00:44:25.599 Um and the structure to keep in mind is that big picture, we can use one labor management code per calendar day per group of providers. 00:44:25.679 --> 00:44:34.719 So it's one code per day, even if you have two providers providing care within the same 24 window, the you can only use one code per calendar day. 00:44:35.280 --> 00:44:46.159 And then the other big picture kind of structural element to keep in mind is you want to choose the code that reflects the highest level of complexity that occurred on that calendar day. 00:44:46.800 --> 00:44:56.400 Um, so for example, I would caution against saying whoever is the day shift person will always be the person who selects the code. 00:44:56.559 --> 00:45:08.079 Um, that seems like a simple way to do it, but I would caution against that because you know, I don't think you will accurately capture all of your patients and their unique labor courses with that approach. 00:45:08.239 --> 00:45:13.440 Um, and I think it will take some trial and error figuring out what works for different providers. 00:45:13.599 --> 00:45:24.400 But um the big picture is that it's one labor management code per calendar day, and it should reflect the highest level of complexity of the care provider on that calendar day. 00:45:25.119 --> 00:45:31.679 Um, and I know this sounds very complicated, but I just want to, you know, soothe anyone who's feeling stressed right now. 00:45:32.079 --> 00:45:34.400 I think this really will become second nature to us. 00:45:34.559 --> 00:45:45.119 So, you know, I think back to starting out in OBGYN, I remember thinking it was very odd

the way that we handle what counts as postpartum day one, right? 00:45:45.280 --> 00:45:48.960 We all know postpartum day one is anytime after midnight after the delivery. 00:45:49.119 --> 00:45:50.880 And even if you deliver at 10 p.m. 00:45:51.519 --> 00:45:58.400 for the purposes of rounding the next morning, that counts as postpartum day one, even if it's been only a few hours since the patient had their baby. 00:45:58.639 --> 00:46:02.320 And you know, that's all second nature to us now. 00:46:02.480 --> 00:46:10.159 And I think that this concept of one code per calendar day, I honestly think it's gonna become second nature to us the same way postpartum rounding has. 00:46:10.239 --> 00:46:14.880 Like the structure will will click, I think, as we start rolling out the new code set. 00:46:17.920 --> 00:46:18.480 Awesome. 00:46:18.639 --> 00:46:21.280 Uh picking uh piggybacking off of that, uh, Dr. 00:46:21.519 --> 00:46:25.039 Horton, how does this work for labor management in a call group? 00:46:26.320 --> 00:46:33.599 Yeah, I can, and I think the way I'll answer this is I want to walk us through a a couple of different scenarios. 00:46:33.840 --> 00:46:38.159 So take I'm in a call group, we switch out every approximately 12 hours. 00:46:38.400 --> 00:46:47.920 When I'm um at a hospice at one of our facilities, I'm a general habituan uh doing clinic at a different um and so we switch out every 12 hours. 00:46:48.079 --> 00:46:59.519 And so I may have a patient that comes in and I do the admission of that patient, uh, do their all of their work, get them settled in and start their start their labor. 00:46:59.679 --> 00:47:06.320 I hand that patient off to someone for the PM shift, there that person is there across midnight. 00:47:06.480 --> 00:47:09.280 And then on the next day, they continue to labor. 00:47:09.440 --> 00:47:15.119 So for that first day, the only thing that was sort of occurred was admission and the labor management. 00:47:15.280 --> 00:47:20.159 The only thing, lots of things, but all baked into an initial labor management code. 00:47:20.320 --> 00:47:26.480 And then on the second, so even though there are two pay two people there, uh, we are in the same call group. 00:47:26.719 --> 00:47:35.920 And so for that one day, when we're looking across that admission, there's a single code for that initial for that calendar date for the initial labor management. 00:47:36.159 --> 00:47:47.280 Say on the second day, she continues to labor or they continue to labor and they end up having failure to progress, and they need a c section. 00:47:47.440 --> 00:47:51.679 And so for that, and they you perform a primary cesarean section. 00:47:51.920 --> 00:48:05.360 So for that day, looking back upon that admission, that one person may have labored them in the daytime, a second person took over that care, then did more labor management, and then did a c-section. 00:48:05.519 --> 00:48:15.280 For that whole calendar date, when you review it, there was a single code for subsequent labor management, and then you have the primary C-section code. 00:48:15.599 --> 00:48:29.519 And this is the most common scenario for a primary section, is that it's coming from the floor, from you know, arrest of dilation, from arrest of dissent, or potentially non-reassuring fetal testing. 00:48:29.679 --> 00:48:38.400 And so when you do these, when you use these codes, once the code is signed, next that is all within the same calendar date. 00:48:38.559 --> 00:48:48.960 On the next calendar date, when they've moved to the postpartum unit, the person that sees them in the morning sees them does rounding, then they have concerns later on that day. 00:48:49.119 --> 00:48:52.480 A different person, an evening person, comes and sees them at night. 00:48:52.800 --> 00:49:00.079 For all of that rounding that was done to that day, for the whole of that calendar date, you have one hospital, subsequent hospital visit. 00:49:00.239 --> 00:49:02.960 And so for each date, you have one management. 00:49:03.119 --> 00:49:07.679 And I know the codes I mentioned, I happen to mention the primary c-section. 00:49:07.760 --> 00:49:11.679 And so just to reiterate that because there's some nuances to that. 00:49:11.840 --> 00:49:21.440 You'll notice that I mentioned that it is true that the typical primary C-section happens when it's coming off, uh coming off the floor, is what I would say, coming off labor unit. 00:49:21.599 --> 00:49:30.159 And so that patient has already had, in most cases, in a typical patient, an initial labor management code um place. 00:49:30.480 --> 00:49:35.119 And so they had an HMP as part of their hospital that encounter experience. 00:49:35.360 --> 00:49:51.679 Now it is important to know though that again, if this primary uh C-section is done as a scheduled, the work of that HMP was not is not in that, not baked into that code, was not a part of that sort of review of what is valued into that code. 00:49:51.840 --> 00:50:03.519 And so on that day, if it's a scheduled, not labored, but a scheduled C-section, then we would do a HMP code and the primary C-section code. 00:50:03.679 --> 00:50:06.719 This is different from the repeat C-section. 00:50:07.199 --> 00:50:10.239 Repeat C-section, so you always think about what is the typical patient. 00:50:10.880 --> 00:50:15.199 And that's how we create the work and we describe the work that is in these codes. 00:50:15.280 --> 00:50:21.119 And so for a repeat C-section, that typical patient is someone who's typically scheduled. 00:50:21.360 --> 00:50:28.000 And so for that patient, we would code a just single code, the repeat C-section itself. 00:50:28.079 --> 00:50:31.360 We would not code an HMP with the repeat. 00:50:31.519 --> 00:50:33.519 Now you ask yourself, well, what about feedbacks? 00:50:33.599 --> 00:50:34.480 What about TOLAX? 00:50:34.960 --> 00:50:42.239 Well, for trial of labor at C-section, you would code exactly the same as the scenario

we just discussed. 00:50:42.400 --> 00:50:45.599 They admission you admit them with initial labor code. 00:50:45.760 --> 00:50:54.719 On the second day, you're managing labor, it's a subsequent labor management code, but they fail TOLAC, they just don't dilate, you take them to a C-section. 00:50:54.880 --> 00:50:59.360 You'd use the repeat C-section code because that is the work you're being done. 00:50:59.519 --> 00:51:07.760 Now there may be changes to and reduction of a because that includes some of the work, but you always code for the work that you're doing. 00:51:07.840 --> 00:51:13.519 And so in this case, you'd code for the repeat code because that's the that's the procedure that you're performing. 00:51:13.760 --> 00:51:16.559 And we will put out more information on this. 00:51:16.639 --> 00:51:20.320 So don't feel like this is the last and only time you'll hear information. 00:51:20.480 --> 00:51:28.960 A lot of this is nuanced, and you will keep getting more and more information from us to help understand all of these different scenarios that we're bringing up. 00:51:30.800 --> 00:51:31.440 Great. 00:51:31.679 --> 00:51:32.239 Uh Dr. 00:51:32.400 --> 00:51:41.280 Leggett, how do we code um if you are uh supervising CNMs uh during a patient's labor to process or labor's process? 00:51:43.039 --> 00:51:58.960 So whether you're supervising CNMs or other qualified healthcare providers, or even if you're providing patient care directly, the same rules are gonna apply, which is we can only build one labor management code per calendar day per practice. 00:51:59.119 --> 00:52:03.840 So if your CNM is part of your group, then only one code can be used. 00:52:04.000 --> 00:52:10.239 Um, whether you have that code go in under the provider or the CNM, that's up to you and your practice. 00:52:10.480 --> 00:52:16.239 But uh, you would not both code because it's only one labor management code per calendar day. 00:52:16.480 --> 00:52:18.480 This is gonna keep it short and sweet. 00:52:19.599 --> 00:52:20.000 Great. 00:52:20.480 --> 00:52:21.440 Uh back to Dr. 00:52:21.519 --> 00:52:21.840 Horn. 00:52:22.079 --> 00:52:26.239 Are there specific guidelines for documenting labor management and delivery? 00:52:28.000 --> 00:52:35.280 I mean, the you think about this as how you would code for all of your patients in any hospital. 00:52:35.440 --> 00:52:45.199 And so it'd be what is what is the physical that you're performing, what is the um what is the uh the management you're performing? 00:52:45.280 --> 00:52:47.519 And so think about it, what are you reviewing? 00:52:47.679 --> 00:52:56.159 So think about it in the eyes of when you look at sort of sort of the hospital code themselves and the what you currently do, you just mimic that. 00:52:56.719 --> 00:52:59.519 We're used to doing this when we're in the hospital. 00:52:59.599 --> 00:53:02.079 And so it'll be really important to that. 00:53:02.159 --> 00:53:05.280 You've got your, you know, subjective, you've talked with the patient. 00:53:05.440 --> 00:53:07.039 Is there a physical component? 00:53:07.199 --> 00:53:12.159 But what we've moved away from is the idea of counting things anymore. 00:53:12.320 --> 00:53:24.079 And so it's really focusing on the medical management and the medical decision making that you're being done, that you're going through, and that you're documenting that medical decision making. 00:53:24.239 --> 00:53:33.519 And so, kind of, I know Cecilia and I are really trying to drive this home, but we really mean it because it's gonna be super important and it may be a change for you, maybe not. 00:53:33.760 --> 00:53:36.559 But what are all of the conditions that the patient has? 00:53:36.719 --> 00:53:39.360 What how did you consider those different conditions? 00:53:39.599 --> 00:53:42.960 What are the results and/or the imaging that you reviewed? 00:53:43.199 --> 00:53:47.119 What was your plan to handle and manage each of these conditions? 00:53:47.280 --> 00:53:52.000 And this is what will guide you towards the complexity of the code itself. 00:53:52.239 --> 00:54:00.800 And the other thing to really remember is this this coding structure is really an upgrade for us because it's not just a one-size-fits-all approach. 00:54:01.039 --> 00:54:06.719 It has a simplicity to it that if you know it's either straightforward or it's not. 00:54:06.880 --> 00:54:27.039 But when we do have a complex, we are coding for complex, we need to make sure that we're documenting the things that we've often taken for granted, but how much things go through our mind, all the things that we do, the things that we review, and we put it down into the medical record to back up all of the things that we're coding for. 00:54:27.679 --> 00:54:29.440 Yeah, that is such a great point. 00:54:29.519 --> 00:54:36.960 And I also want to highlight just as we are adapting to this, these new codes, the payers are also adapting. 00:54:37.199 --> 00:54:43.440 So let's not make them guess about what services we're providing or the complexity of the clinical situation. 00:54:43.679 --> 00:54:47.599 A lot of the times our payers aren't clinicians necessarily. 00:54:47.679 --> 00:54:54.480 And so we don't want them having to review a note and try and figure out if they think it's complex or not. 00:54:54.559 --> 00:55:01.440 Let's really paint a picture for our payers so that they understand the care that we're providing. 00:55:01.679 --> 00:55:04.880 I think that that will go a long way as we're all transitioning. 00:55:07.119 --> 00:55:07.440 Awesome. 00:55:07.599 --> 00:55:08.320 Thank you both, Dr. 00:55:08.480 --> 00:55:09.039 Horn and Dr. 00:55:09.119 --> 00:55:12.480 Leggett, for your thorough uh answers to these important questions. 00:55:14.559 --> 00:55:21.679 ACOG provides several resources to assist you in this transition, including our coding courses and podcast episodes. 00:55:24.000 --> 00:55:30.000 We encourage you all to explore more ACOG resources to stay ahead of the changes to the 2027 Obsession Codes. 00:55:30.159 --> 00:55:37.920 We urge you to join us in New Orleans on November 7th for more details on the new OP codes and other new coding and billing policies for the year. 00:55:38.159 --> 00:55:40.639 You do not have to be an ACOG member to register. 00:55:42.559 --> 00:55:47.679 I want to round out this town hall with ACOG's recommendation that everyone switch over by September 1st. 00:55:47.920 --> 00:55:56.800 You can scan this QR code to view our uh provider toolkit that goes into detail about the transition to new maternity codes and what that means for our members. 00:55:58.800 --> 00:56:03.039 In our next town hall, we will be covering procedures and postpartum on June 30th. 00:56:03.199 --> 00:56:08.719 You can access our first town hall on ENM for antipartum care recording on our website. 00:56:11.599 --> 00:56:20.079 And finally, if your question was not addressed, please submit it through our portal available at this QR link at um acog coding.com. 00:56:20.480 --> 00:56:33.440 As the town halls conclude, the recordings of the webinars will be available online in a few days, and the audio will be available on ACOG's Payment and Practice Podcast, available wherever you listen to your podcast, including Spotify and Apple Music. 00:56:33.760 --> 00:56:36.960 Thank you all for your time this evening and have a great rest of your night.