Obstetrics & Gynecology billing and accounts receivable

OB/GYN runs two revenue cycles at once. Maternity is a global package: months of antepartum visits, the delivery and postpartum care bundled into one claim filed after the birth. The gynecology side bills procedure by procedure — colposcopy, LEEP, ablation, hysteroscopy, laparoscopic hysterectomy. A mistake at the first prenatal visit surfaces only when the delivery claim goes out months later.

Where the money leaks in obstetrics & gynecology

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Global maternity package billed in full after the patient transferred care mid-pregnancy, when only the antepartum visits actually rendered here should have been itemised.
• A well-woman preventive exam and a problem visit on the same day, with the problem work never documented separately, so the problem visit denies as part of the preventive.
• The IUD or contraceptive implant insertion pays, but the device supply is left off the claim or denies because the invoice the payer asked for was never sent.
• A follow-up obstetric ultrasound written up as routine, with no indication in the note, denied as not medically necessary and never appealed with the findings that prompted it.
• Coverage checked once at the first prenatal visit and never rechecked, so the delivery claim months later goes to a plan the patient has already left.
• Prior authorization obtained for an open hysterectomy when the case was completed laparoscopically, and nobody reconciled the operative report against the approved request.

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working obstetrics & gynecology, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. Matched from: “Global maternity package billed in full after the patient transferred care mid-pregnancy, when only the antepartum visits actually rendered here should have been itemised.”
• CO-198 — Authorization limit exceeded
  An authorization exists. The problem is that you went past what it allowed — more units, more visits, or a longer date range than was approved.
  Recovered by being answered with the document the payer names. Matched from: “A follow-up obstetric ultrasound written up as routine, with no indication in the note, denied as not medically necessary and never appealed with the findings that prompted it.”
• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Coverage checked once at the first prenatal visit and never rechecked, so the delivery claim months later goes to a plan the patient has already left.”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Prior authorization obtained for an open hysterectomy when the case was completed laparoscopically, and nobody reconciled the operative report against the approved request.”
• CO-226 — Requested information not supplied
  The payer asked you for something, and either nothing arrived or what arrived did not answer the question.
  Recovered by being answered with the document the payer names. Matched from: “Prior authorization obtained for an open hysterectomy when the case was completed laparoscopically, and nobody reconciled the operative report against the approved request.”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a obstetrics & gynecology AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

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