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Based on the non-significant trend towards harm associated with clindamycin use in patients with iNABS infections, adjunctive clindamycin treatment should be avoided in patients with confirmed iNABS infection in the absence of other clinical indications, such as necrotising fasciitis or suspected streptococcal toxic shock syndrome.

Our real-world data supports the use of adjunctive clindamycin in patients with iGAS infections. These data could help inform the design and conduct of further trials, and underscore the importance of doing translational studies to explore the potential mechanisms of harm or the absence of benefit of clindamycin in patients with iNABS infections. This treatment strategy is largely based on evidence from in vitro and animal models, as robust clinical data are scarce.

We searched for primary research and reviews published from database inception up to Oct 30, , with no language restrictions. The search yielded studies. Most of these studies reported a trend towards survival benefit of adjunctive clindamycin therapy for invasive iGAS infections. By contrast to these studies, a prospective surveillance study of 62 critically ill patients with iGAS infection found no association between clindamycin treatment and survival appendix pp 25— Propensity matching and adjusting for the severity of acute illness by use of organ failure scores strengthened the validity of our results.

Adjunctive clindamycin also improved survival in patients with iGAS infections who did not have shock or necrotising fasciitis, suggesting that wider use of this therapy in less severely affected patients could be warranted.

Given the absence of benefit and possible harm observed from adjunctive clindamycin in patients with iNABS, this therapy appears to have no beneficial role in the treatment of these infections. We also thank David Fram and Huai Chen of Commonwealth Informatics for their assistance with data mapping and curation, and Kelly Byrne for her assistance with formatting the manuscript text, figures, and tables. The preliminary findings of this study were presented at the annual conference of the Infectious Diseases Society of America on Oct 4, , in San Diego, and on Oct 2—6, , in Washington.

Lancet Infect Dis. Author manuscript; available in PMC May 1. Author information Copyright and License information Disclaimer. Contributors SSK conceived the study. AB and SSK did the literature search.

AB and SSK wrote the draft of the manuscript. All authors reviewed and critically revised the manuscript for important intellectual content. Copyright notice. The publisher's final edited version of this article is available at Lancet Infect Dis. This article has been corrected. See the correction in volume 21 on page Associated Data Supplementary Materials 1.

Methods For this retrospective multicentre cohort study, we used a dataset from patients in the Cerner Health Facts database, which contains electronic health-based data from US hospitals.

Interpretation Real-world data suggest that increased use of adjunctive clindamycin for invasive iGAS infections, but not iNABS infections, could improve outcomes, even in patients without shock or necrotising fasciitis. Introduction Group A streptococcus is a leading cause of invasive bacterial disease worldwide, with over half a million cases occurring each year.

Methods Data source and study population For this retrospective multicentre cohort study, we used a dataset from patients in the Cerner Health Facts database operated by Cerner Corporation, Kansas City, MO, USA , which contains de-identified electronic health record-based data from US hospitals.

Open in a separate window. Figure 1. Procedures Data from centres that reported on billing codes, laboratory and medication orders, and microbiology records were used for analysis. Statistical analysis Given differences in virulence factors, the propensity for invasive disease, and associated mortality, iGAS and iNABS infection cohorts were analysed separately.

Respiratory 82 Primary bacteraemia Secondary bacteraemia Necrotising fasciitis 12 1. Treatment-related Intensive care unit stay Northeast South West Bed capacity..

Refers to norepinephrine, epinephrine, phenylephrine, and dopamine administered within a h period either side of culture sampling. Role of the funding source The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Figure 2. Figure 3. Figure 4. Figure 5. Supplementary Material 1 Click here to view. Footnotes Declaration of interests We declare no competing interests. References 1. The global burden of group A streptococcal diseases. Lancet Infect Dis ; 5 : — The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, — Clin Infect Dis ; 45 : — Human intravenous immunoglobulin for experimental streptococcal toxic shock: bacterial clearance and modulation of inflammation.

J Antimicrob Chemother ; 58 : — Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock: a propensity score-matched analysis from US hospitals. Clin Infect Dis ; 64 : — Polyspecific intravenous immunoglobulin in clindamycin-treated patients with streptococcal toxic shock syndrome: a systematic review and meta-analysis.

Clin Infect Dis ; 67 : — Clindamycin affects group A streptococcus virulence factors and improves clinical outcome. J Infect Dis ; : — Invasive group A streptococcal infections in Florida.

South Med J ; 96 : — Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study. Secular trends in incidence of invasive beta-hemolytic streptococci and efficacy of adjunctive therapy in Quebec, Canada, — PLoS One ; 13 : e Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome—a comparative observational study. The Canadian Streptococcal Study Group.

Population-based surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario group A streptococcal study. Am J Med ; : 18— Morbidity and mortality of patients with invasive group A streptococcal infections admitted to the ICU. Chest ; : — Effectiveness of clindamycin and intravenous immunoglobulin, and risk of disease in contacts, in invasive group a streptococcal infections.

Clin Infect Dis ; 59 : — Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr Infect Dis J ; 18 : — Executive summary: practice guidelines for the diagnosis and management of skin and soft tissue infections: update by the Infectious Diseases Society of America.

World J Emerg Surg ; 9 : Cunha CB. Viridans streptococci, nutritionally variant streptococci, and groups C and G streptococci. Principles and practice of infectious diseases. Ninth edition. Philadelphia: Elsevier, — Bacteremia due to beta-hemolytic streptococcus group G: increasing incidence and clinical characteristics of patients.

Am J Med ; : — Invasive group A, B, C and G streptococcal infections in Denmark — epidemiological and clinical aspects. Clin Microbiol Infect ; 11 : — Population-based study of invasive disease due to beta-hemolytic streptococci of groups other than A and B.

Clin Infect Dis ; 48 : — Complete genome sequencing and analysis of a Lancefield group G Streptococcus dysgalactiae subsp. BMC Genomics ; 12 : Characterization of group C and G streptococcal strains that cause streptococcal toxic shock syndrome. J Clin Microbiol ; 42 : — Linezolid effects on bacterial toxin production and host immune response: review of the evidence. Curr Ther Res Clin Exp ; 73 : 86— Case definitions for infectious conditions under public health surveillance.

Med Care ; 43 : — Balance diagnostics after propensity score matching. Ann Transl Med ; 7 : Stuart EA. Matching methods for causal inference: a review and a look forward. 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. 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. 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. A 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 comprises the initial prenatal history and examination, as well as subsequent prenatal history and physical examination. This includes:. Separate CPT codes should not be reimbursed as part of the global package. As such, including these procedures in the Global Package would not be appropriate for most patients and providers.

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. The following is a comprehensive list of all possible CPT codes for full term pregnant women. Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery.

Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care. Some pregnant patients who come to your practice may be carrying more than one fetus. In such cases, certain additional CPT codes must be used. ACOG has provided the following coding guidelines for vaginal, cesarean section, or a combination of vaginal and cesarean section deliveries.

To ensure accurate maternity obstetrical care medical billing and timely reimbursements for work performed , make sure your practice reports the proper CPT codes. If both twins are delivered via cesarean delivery, report code routine obstetric care including antepartum care, cesarean delivery, and postpartum care.

This is because only one cesarean delivery is performed in this case. However, if the cesarean delivery is significantly more difficult, append modifier 22 to code When reporting modifier 22 with , a copy of the operative report should be submitted to the insurance carrier with the claim. Some 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:. 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:. In this case, special monitoring or care throughout pregnancy is needed, which may require more than 13 prenatal visits. All these conditions require a higher and closer degree of patient care than a patient with an uncomplicated pregnancy. As such, visits for a high-risk pregnancy are not considered routine. The claim should be submitted with an appropriate high-risk or complicated diagnosis code. NOTE: When a patient who is considered high risk during her pregnancy has an uncomplicated delivery with no special monitoring or other activities, it should be coded as a normal delivery according to the usual codes.

Maternal-fetal medicine specialists, also known as perinatologists , are physicians who subspecialize within the field of obstetrics. They focus on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy. Make sure you double check all insurance guidelines to see how MFM services should be reported if the provider and MFM are within the same group practice. When reporting ultrasound procedures, it is crucial to adhere closely to maternity obstetrical care medical billing and coding guidelines.

In particular, keep a written report from the provider and have images stored on file. As per AMA CPT and ultrasound documentation requirements, image retention is mandatory for all diagnostic and procedure guidance ultrasounds.

CPT does not specify how the images are to be stored or how many images are required. Modifiers may be applicable if there is more than one fetus and multiple distinct procedures performed at the same encounter. Incorrectly reporting the modifier will cause the claim line to be denied. The following CPT codes cover ranges of different types of ultrasound recordings that might be performed.

Make sure your practice is following correct guidelines for reporting each CPT code. It is essential to read all the parenthetical guidelines that instruct the coder on how to properly bill the service for multiple gestations and more than one type of ultrasound.

The following is a comprehensive list of eligible providers of patient care with the exception of residents, who are not billable providers :. Depending 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.

Here at Neolytix, we are more than happy to assist your practice with billing, coding, EMR templates, and much more. By Ritu Bhatnagar. Submit claims based on an itemization of maternity care services. What do you need to know about maternity obstetrical care medical billing? We will go over: Different types of services rendered The global maternity care package: what services are included and excluded? Table of Contents. Short Handed? Try Hourly Services.

Complex reimbursement rules and not enough time chasing claims. We can help. Contact Us. The Global Obstetrical Package.

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