<img height="1" width="1" src="https://www.facebook.com/tr?id=2288618241379167&amp;ev=PageView &amp;noscript=1">

3 Guidelines Every OB-GYN Practice Should Follow

28 Feb 2019

Without the support of a built-in billing department, private practice OB/GYN physicians face a number of challenges other practitioners connected with hospitals and their networks don’t.

3 guidelines header-01So it’s especially important that private practices follow industry-specific guidelines to ensure compliance with today’s evolving healthcare laws and to ensure practices recoup the maximum amount billable to insurance companies.

Let’s take a look at just a few of the critical guidelines every OB/GYN practice and its billing department should follow.

#1. The ACA

The Patient Protection and Affordable Care Act (or ‘ACA’) includes guidelines, some of which were implemented immediately in 2010 when it was signed into law, and some which were designed to roll out gradually.

A medical billing department has to know which aspects of the law are applicable in any given year.

In addition, certain aspects of the original legislation have been stalled or repealed with changing administrations, further emphasizing a billing department’s need to keep current.

Just some of the ways ACA guidelines can affect how OB/GYN physicians bill for services include:

  • Increased coverage for individuals previously unable to afford healthcare services which mean private practices must adapt to accommodate a higher volume of patients, visits and medical claims.

  • Any change in the law has the potential to affect patient demographics, volume, and other aspects of running a private practice, so its billing department has to keep current with the latest guidelines.

  • Many OB/GYN-related visits are now classified as preventative, and so are provided to covered individuals free from a copay. A billing department must know what visits and procedures are affected, including annual exams, preconception care, family planning counseling and a variety of disease screenings such as HPV, cervical cancer and HIV.

Changing healthcare legislation is just one reason any private OB/GYN practice should have a highly skilled, well informed back office to perform its billing functions, preferably staffed by people able to focus exclusively on these guidelines.

Are You Billing the Maximum Amount for Your OB-GYN Services?

#2. ICD-10 Coding Guidelines

As any physician well knows, the International Classification of Diseases, Tenth Revision (or ‘IDC-10’) is an intricate system of codes governing how physicians analyze and classify all diagnoses, symptoms, and procedures--- and this, of course, includes OB/GYN specific healthcare services.

Because these guidelines are both complex and stringent, denial of claim notices are inevitable if a private practice billing office isn’t highly trained, technically proficient, extremely accurate and up to date on any changes in these guidelines.

Some of the more frequent denial explanations include:

  • 16: Claim lacks information or has errors

  • 18: Duplicate claim/service

  • 96: Non-covered charge(s)

  • 234: Procedure is not paid separately

Denied or delayed claims have an obvious negative effect on a private practice’s cash flow, which makes following these coding guidelines a must for the success of any OB/GYN practice.

3 guidelines-highlighted-01

#3. Medicare, Medicaid, and Private Insurance Plan Guidelines

Understanding and adhering to insurance plan guidelines whether public or private are crucial to an effective private practice billing function.  


The Centers for Medicare and Medicaid Services (or ‘CMS’) issue guidelines for physicians treating patients under these plans. Even practices without a high volume of these types of insured individuals must nonetheless comply with CMS guidelines.

Since CMS policies outline baseline costs for each medical procedure and treatment available, a billing department must necessarily follow its guidelines if claims are to be accepted.

For example, Clinical Qualities Measures Basics, which is overseen by CMS, takes the following into consideration for evaluating providers:

  • Patient and Family Engagement

  • Patient Safety

  • Care Coordination

  • Population/Public Health

  • Efficient Use of Healthcare Resources

  • Clinical Process/Effectiveness

These components can have obvious implications for medical billing, especially the guidelines around the efficient use of healthcare resources and clinical process/effectiveness.

Private Health Insurance

One important qualification for an efficient medical billing specialist is an expertise in the varied and complex health insurance plans available on the market today and their stipulations for coverage.  

Billing specialists must be fluent in the guidelines, terminology, and contingencies these private insurance plans use; and, must be proficient in addressing issues like in- and out-of-network claims, cash discount implications and payment plan options.

Often, it is a private OB/GYN practice billing department that must be available to explain things like the way billing works throughout pregnancy, including questions about prenatal care and delivery within or outside of a calendar year.  

OB/GYN patients often want to anticipate and plan for specific costs around labor and delivery, postnatal care and scans, tests, and emergency treatments. A billing department well versed in the patient’s health care plan guidelines is invaluable.  

When To Turn to the Professionals

At Heartland Medical Billing & Consulting, we know that understanding and complying with the many guidelines which affect the medical billing function can be overwhelming for private practice OB/GYN physicians and their office staff.

Outsourcing this function alleviates the pressure and stress associated with all aspects of medical billing, including the burden of having to keep current with the latest guidelines governing how medical claims are coded and billed.

We invite you to visit us here to find out more about how Heartland Medical Billing & Consulting can be a complete medical billing solution for your OB/GYN practice.

About the Author

Stacey Dill

With over 20 years of experience in medical billing and coding, Stacey started Heartland Medical Billing & Consulting in 2008. Over the years, she has developed expertise in the most complicated and ever changing medical billing codes, including OB/GYN, neurosurgery, vision and more.

Receive updates from the blog.