4. 59025 : Fetal non-stress test: 76805: Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation + 76810: each additional gestation (List separately in addition to code for primary . Randomised comparison of routine versus highly selective use of Doppler ultrasound in low risk pregnancies. Contractor Number . For Vaginal Deliveries Bill vaginal deliveries for multiples using the guidelines outlined below: For the first infant (Baby A): Penning S, Garite TJ. } Matias DS, Costa RF, Matias BS, et al. Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk pregnancies. Hypertension. Endometrial thickness was found to be higher in the patients with malign histopathology compared with the patients of benign histopathology. Because standards for the study technique, gestational age, and criteria for an abnormal test are lacking, uterine artery Doppler studies should not be considered to be a required medical practice in low or high risk populations.". Afterward, he tries an electronic larynx to stimulate the fetus with noise through the patient's abdomen. To learn more about using ProviderOne to file your claims, use our ProviderOne resources section. Mean maternal serum YKL-40 levels were lower in women who subsequently developed early (87.453.07 versus 103.404.29) or late (96.434.06 versus 99.873.63) pre-eclampsia than those who remained normotensive. Perry et al (2020) examined the prognostic value of angiogenic markers and maternal risk factors in pregnant women with hypertension. If the patient is simply hooked up to a monitor during her hospital stay and the ob-gyn occasionally looks at the strip, you should consider that part of her exam and not a separately billable test. UpToDate [online serial]. Comparison of the modified biophysical profile to a 'new' biophysical profile incorporating the middle cerebral artery to umbilical artery velocity flow systolic/diastolic ratio. They stated that although these findings did not support the replacement of uterine artery Doppler analysis in multi-parametric predictive models for PE, they provided novel insights into first-trimester maternal systemic vascular changes that preceded the clinical development of this condition. Park et al (2014) attempted to establish a cut-off value for the sFlt-1/PlGF ratio measured using the Elecsys assay to predict late-onset PE in low-risk pregnancies. If a physician provides any component of antepartum along with postpartum care, but does not perform the delivery, then the services should be itemized by using the appropriate counterpart care code and postpartum care code. Continue with Recommended Cookies. Billing and Claims | Sunshine Health Copayments; Fee-for-Service. Summary ROC curves showed that, among suspected SGA fetuses, the best predictive accuracy of abnormal third-trimester UAD was for perinatal mortality and the worst was for composite adverse perinatal outcome, with areas under the summary ROC curves of 0.90 and 0.66, respectively. Mason GC, Lilford RJ, Porter J, et al. 1990;75(3 Pt 1):464-468. The relationship between ophthalmic Doppler indices and PE could not be a consequence of trophoblast invasion and may be related to maternal hemodynamic adaptation to pregnancy. The authors concluded that the combination of the PAPP-A level and the 2nd trimester sFlt-1/PlGF ratio, and the combination of the 2nd trimester sFlt-1 level with BMI, were better predictors of late-onset PE than any individual marker. Routine fetal and umbilical Doppler ultrasound examination in low-risk or unselected populations did not result in increased antenatal, obstetric and neonatal interventions, and no overall differences were detected for substantive short-term clinical outcomes such as perinatal mortality. Wisconsin Physicians Service Insurance Corporation . Global OB Care Coding and Billing Guidelines, By: Sheila Haynes Coding and Compliance Manager. 8. ins.className = 'adsbygoogle ezasloaded'; If you would like to change your settings or withdraw consent at any time, the link to do so is in our privacy policy accessible from our home page.. Am J Obstet Gynecol. ", According to ACOG guidelines, "[n]o benefit has been demonstrated for umbilical artery velocimetry for conditions other than suspected intrauterine growth restriction, such as post term gestation, diabetes mellitus, systemic lupus erythematosus, or anti-phospholipid syndrome. 1991;98:956-963. Routine and continuous fetal monitoring is considered to be included in the global. First diastolic peak velocity of ophthalmic artery Doppler at a cut-off of 23.3cm/s showed modest sensitivity (61.0 %; 95 % CI: 44.2 to 76.1%) and specificity (73.2 %; 95 % CI: 66.9 to 78.7 %) for the prediction of early-onset PE (AUC, 0.68; 95 % CI: 0.61 to 0.76). OB Global Billing Guidelines. 90791 90792 . (adsbygoogle = window.adsbygoogle || []).push({}); Gybel-Brask D, Hogdall E, Johansen J, et al. A total of 17 observational studies (including 7,552 fetuses either diagnosed with suspected SGA (n = 3,461) or later diagnosed as a SGA neonate (n = 4,091)) met the inclusion criteria; no RCTs met the inclusion criteria. The competing risks model was used to estimate the individual patient-specific risks of delivery with PE at less than 37 and greater than or equal to 37 weeks' gestation and determine the AUC and DR, at 10 % FPR, in screening by a combination of maternal demographic characteristics and medical history with biomarkers. 1999;26(2):259-274. You would report this service with 59025 because the ob-gyn is using the NST to determine fetal status. YKL-40, a 38-kDA macrophage-derived glycoprotein, is a member of the "mammalian chitinase-like proteins". Acta Obstet Gynecol Scand. list-style-type: decimal; Goffinet F, Paris-Llado J, Nisand I, Breart G. Umbilical artery Doppler velocimetry in unselected and low risk pregnancies: A review of randomised controlled trials. Stamford, CT: Appleton & Lange; 1999:201-227. 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care. Billing Guidelines CPT code, Read More CPT Code 44140 | Description & Clinical InformationContinue, Your email address will not be published. Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre-and post-operative care associated with the procedure or service performed. Washington, DC: ACOG; December 1994. Madazli R, Kuseyrioglu B, Uzun H, et al. Evidence for the outcome of stillbirth was graded according to regimen subgroups -- with a moderate quality rating for stillbirth (fetal/umbilical vessels only) and a low quality rating for stillbirth (fetal/umbilical vessels + uterine artery vessels). Coding Billing Guidelines. Naef RW 3rd, Morrison JC, Washburne JF, et al. The PSV ratio also improved the prediction of term PE provided by maternal factors alone (from 33.8 % to 46.0 %), maternal factors, MAP plus UtA-PI (46.6 % to 54.2 %), maternal factors, MAP, UtA-PI plus PlGF (45.2 % to 53.4 %) and maternal factors, MAP, UtA-PI, PlGF plus sFlt-1 (from 43.0 % to 51.2 %), at FPR of 10 %. Serum YKL-40 and apelin concentrations were measured. The AUC increased from 0.72 to 0.78 when the PMDV was incorporated into a prediction model based on clinical variables, demonstrating that this marker increased the discriminatory capability of the model. Overall summary of test accuracy was provided by the diagnostic odds ratio (OR). 53. All included studies had clear description of the index and reference tests, avoidance of verification bias and adequate follow-up. The mother marks the strip when she feels movement throughout the 30-40 minutes of the test. 2006;108(2):457-464. Serum IMA, complete blood count (CBC), liver function tests (LFT), renal function tests (RFT), albumin, and C-reactive protein (CRP) were measured in the mothers immediately before birth, and in the cord blood and serum of the newborns at 6 and 24 hours after birth. .strikeThrough { 1998;24(6):453-460. Lancet. NST Procedure Code 59025 Components of a NST - V i biliVariability Short term variability (STV) . Seshadri Reddy V, Munikumar M, Duggina P, Varma N. A diagnostic test accuracy meta-analysis of maternal serum ischemia-modified albumin for detection of preeclampsia. One of the belts is used for measuring fetal contractions and movements. Duan and colleagues (2017) noted that identifying women at risk of PE by maternal serum screening is conducive to prompt gestational management and thereby improve both maternal and perinatal outcomes. These researchers carried out a systematic review to evaluate the quality of the evidence available to-date regarding the relationship between prenatal stress and maternal-fetal hemodynamics. In a systematic review and meta-analysis, Kalafat and colleagues (2018) determined the accuracy of ophthalmic artery Doppler in pregnancy for the prediction of PE. When the same group physician and/or other healthcare professional provides all components of the OB package, the appropriate CPT code for the Global OB care is reported. Furthermore, an UpToDate review on Preeclampsia: Clinical features and diagnosis (August and Sibai, 2021) does not recommend screening of placental growth factor (PIGF) as a management tool. I know that for a Medicare [], Additional Weakness Will Show Need for Mesh, Question: I need clarification on codes 618.81-618.82. BILLING Guideline for CPT Code 59425, 59409, S5100 and T1023 Middle cerebral artery flow velocity waveforms in normal and small-for-gestational-age fetuses. All women had ultrasound and blood sample collection at the nuchal translucency scan, a 20-week malformation scan and 25-week and 32-week fetal growth examinations. The authors concluded that it is possible to predict the discordant twins birth using MCA Doppler velocimetry, but the EFW assessment remains the most accurate method. /* aetna.com standards styles for templates */ } A comparison of the mean ophthalmic artery Doppler parameter values between women with and those without PE showed statistically significant differences in several parameters: peak systolic velocity, end-diastolic velocity, mean velocity, peak meso-diastolic velocity (PMDV) and peak ratio. 1997;56(8):1981-1988. For 7 or more visits: Use CPT 59426- Complete antepartum care is limited to one beneficiary pregnancy per provider. 1999;33(2):143-151. 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The authors concluded that serum IMA in addition to the prevalence of SGA were significantly increased in the PE group; thus, cord blood IMA might be a predictive biomarker for SGA in PE pregnancies. In a Cochrane review, Alfirevic et al (2015) examined the effects of routine fetal and umbilical Doppler ultrasound on obstetric practice and pregnancy outcome in unselected and low-risk pregnancies. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. lo.observe(document.getElementById(slotId + '-asloaded'), { attributes: true }); 2001;56(11):707-719. Umbilical artery Doppler velocimetry has not been shown to impact other perinatal outcomes, such as gestational age at birth, birth-weight, Apgar scores, and cesarean birth rates. Second, most of the included studies were hampered by lack of blinding of the UAD measurements. Discordant fetal growth is common in multiple gestation and usually is defined by a 15 to 25 % reduction in the estimated fetal weight of the smaller fetus when compared with the largest. J Matern Fetal Neonatal Med. ACOG Practice Bulletin No. Here you will find information for assessing coverage options, guidelines for clinical utilization management, practice policies, the provider manual and support for delivering benefits to our members. This was probably due to the low number of patients with PE, and the fact that PE results from various pathophysiologic mechanisms that may alter the markers in different ways. 2011;39(6):619-635. A nurse will listen to and record the baby's heartbeat while the baby is resting and while the baby . Clinical Guidelines, Standards & Quality of Care Permits, Licenses & Certification All Health Care Professionals & Patient Safety Health Topics A to Z Health Facilities Compare Health Care Providers Adult Care Facilities/Assisted Living Home Care & Hospice Hospitals & Clinics New York State Veterans Homes Nursing Homes School Based Health Centers Combining these first trimester parameters did not improve the predictive efficiency of the models. The authors concluded that a high ophthalmic artery PMDV in the second trimester of pregnancy was an independent predictor of PE that increased the discriminatory ability of clinical markers, as well as of models that included clinical variables and UtA Doppler indices. Two independent reviewers selected studies, extracted data and assessed quality. } Ultrasound Obstet Gynecol. Billing for service without the global package: When the patient transfers care mid-pregnancy: . Sarno M, Wright A, Vieira N, et al. Lancet. The delivery only codes should be reported by the same group physician for a single gestation when: https://www.acog.org/practice-management/coding/coding-library, AMA CPT Content Module: Global OB codes Reporting and Use, 2023 RT Welter All Rights Reserved. Literature on the 7 most studied serum markers (A-disintegrin and metalloprotease 12 [ADAM 12], free -subunit of human chorionic gonadotropin [f-hCG], Inhibin A, Activin A, PP13, placental growth factor [PlGF], and pregnancy-associated plasma protein A [PAPP-A]) and Ut-A Doppler was primarily selected. Subsequent codes related to this code include: 96373 - therapeutic, prophylactic, and diagnostic substance by intra-arterial injections and infusions Use of umbilical artery Doppler should be individualized, and a plan of management based on the results should be put in place. A total of 31 (7 %) patients developed PE, including 9 (2 %) who needed delivery before 34weeks (early PE) and 22 (5 %) with late PE. Alfirevic Z, Stampalija T, Gyte GM. The predictors with the best test performance were BMI greater than 35 kg/m2 , with a specificity of 92 % (95 % CI: 89 to 95 %) and a sensitivity of 21 % (95 % CI: 12 to 31 %); BMI greater than 25 kg/m2 , with a specificity of 73 % (95 % CI: 64 to 83 %) and a sensitivity of 47 % (95 % CI: 33 to 61 %); 1st-trimester UtA pulsatility index or resistance index of greater than 90th centile (specificity 93 % (95 % CI: 90 to 96 %) and sensitivity 26 % (95 % CI: 23 to 31 %)); PIGF (specificity 89 % (95 % CI: 89 to 89 %) and sensitivity 65 % (95 % CI: 63 to 67 %)); and placental protein 13 (specificity 88 % (95 % CI: 87 to 89 %) and sensitivity 37 % (95 % CI: 33 to 41 %)). The ophthalmic artery second to first PSV ratio was significantly increased in PE pregnancies and the PE effect depended on gestational age at delivery; the deviation from normal was greater for early than late PE. *As per ACOG (American College of Obstetricians and Gynecologists) coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier -22 to the global OB code (codes 59400 and 59610) or delivery only code (codes 59409, 59410, 59612, and 59614). UTI, Asthma) during antepartum, Additional E/M visits for complications or high risk monitoring resulting in greater than, However these E/M services should not be reported until after the patient, to identify these visits as separately identifiable from, Inpatient E/M services provided more than 24 hrs before delivery. Performance of first trimester biochemical markers and mean arterial pressure in prediction of early-onset pre-eclampsia. 10. ins.style.display = 'block'; Newnham JP, O'Dea MR, Reid KP, Diepeveen DA. Deren O, Onderoglu L. The value of middle cerebral artery systolic velocity for initial and subsequent management in fetal anemia. 2008;(3):CD006593. Am J Obstet Gynecol. The most commonly interrogated vessels are the umbilical arteries. J Obstet Gynaecol Res. Red flag: If the patient does deliver within 24 hours of admission, you should consider the labor check part of the global. Texas Subscriber
Our billers and coders have great experience which reduces your billing worries and you can focus only on patient care. Gudmundsson S, Marsal K. Umbilical and uteroplacental blood flow velocity waveforms in pregnancies with fetal growth retardation. Tip: Make sure you include labor checks in the global ob codeDo you want to code fetal non-stress test (NST) using 59025? It relies on the premise that fetal oxygenation will be transiently worsened by uterine contractions. Although awareness of fetal movements is associated with improved perinatal outcomes, the quest to define a quantitative "alarm limit" to define decreased fetal movements has so far been unsuccessful, and the use of most such limits developed for fetal movement counting should be discouraged. 2008;100(3):239-243. Seshadri and colleagues (2019) noted that IMA has been widely accepted as a serological biomarker; and it has been proposed as a simple and novel marker of oxidative stress in PE. provider for the same beneficiary, during the same pregnancy. 2015;212(2):127-139. ACOG Practice Bulletin No. Maulik D. Doppler ultrasound of the umbilical artery for fetal surveillance. Patient reports fetal movements as an external monitor records fetal heart rate changes. Neilson JP, Alfirevic Z. Doppler ultrasound for fetal assessment in high risk pregnancies (Cochrane Review). Sound can also be used to induce acceleration of the heart rate of the fetus. Studies where uterine vessels have been assessed together with fetal and umbilical vessels have been included. Contractor Name . However, if a reassuring test is achieved within the first 10 minutes or less, the patient does not have to be monitored for the additional time. 25. Fetal middle cerebral artery Doppler waveforms in twin-twin transfusion syndrome. XLSX ehp.primehealthcare.com A -reactive- NST will show the fetal heart rate accelerate from the baseline 15 beats per minute for a minimum of 15 seconds at least twice during a 10-minute window. TC procedures are institutional and cannot be billed separately by the physician when the patient is: In a covered Part A stay in a skilled nursing facility . 1993;100:733-741. Intrauterine growth restriction. All women underwent UtA Doppler US at 20 to 24 weeks of gestation; 8 of the 262 women (3.0 %) developed late-onset PE. The pulsatility index of the ophthalmic artery did not show a clinically useful sensitivity or specificity at any cut-off for early- or late-onset PE. Hemoglobinopathies (hemoglobin SS, SC, or S-thalassemia), Multiple gestation (with significant growth discrepancy), Post-term pregnancy (greater than 41 weeks gestation), Previous fetal demise (unexplained or recurrent risk), Amniotic fluid index (determination of the amniotic fluid volume), chitotriosidase activity in both maternal and cord serum and. YKL-40 is neither organ- nor tumor-specific. It was developed with consideration of the latest coding methodologies from several sources, including but not limited to: Coding descriptions and instructions as identified in the latest rel ease of the American Medical Furthermore, the false positive rate of this test is quite high, leading to excessive patient anxiety and health care costs. "The patient reports fetal movement as an external monitor records fetal heart rate changes. These services are reported with codes 59025 (Fetal non-stress test) or 59020 (Fetal contraction stress test). CPT Code 0734T CPT 0734T describes remote real-time, motion-capture-based neurorehabilitative, Read More CPT Codes For Remote Body And Limb Kinematic Measurement-Based TherapyContinue, CPT 44140 describes a procedure in which the colon is divided and the two ends are rejoined. Therefore, you would not report a separate NST.Note: For a free PDF of an outpatient fetal monitoring template you can put to use in your practice, e-mail suzannel@eliresearch.com. Yes. Most payers do not cover the NST unless your ob-gyn documented a specific reason,- Engstrom says. } Ob-gyns often use a fetal monitor to determine if a woman is in labor, but that doesn't mean you should report 59025. Furthermore, ophthalmic artery Doppler indices were not adjusted for maternal factors such as alcohol consumption (although the rates of such factors were similar between cases and controls), and raw values rather than multiples of the median (MoM) were used in statistical analyses. Aetna considers Preeclampsia Screen|T1 experimental and investigational for prediction of risk for early onset preeclampsia becauseits effectiveness has not been established. } Although Doppler studies of the ductus venous, middle cerebral artery, and other vessels have some prognostic value for IUGR fetuses, currently there is a lack of randomized trials showing benefit. Nicolaides KH, Bilardo CM, Soothill PW, Campbell S. Absence of end diastolic frequencies in umbilical artery: A sign of fetal hypoxia and acidosis. UpToDate [online serial]. Alternatively, acoustic stimulation is applied to the maternal abdomen for 1 to 2 seconds and the fetal heart rate is recorded. Example: -You might use the decreased fetal movement code (655.73) because the ob-gyn is monitoring the baby,- says Deanna Sherland, CPC, billing/surgery clerk at Midwest Women's Care in Belleville, Ill. Prediction of preeclampsia or intrauterine growth restriction by second trimester serum screening and uterine Doppler velocimetry. Detection rate (DR) was 72 % for a false-positive rate (FPR) of 15 %, an area under the curve (AUC) of 0.81 (95 % CI: 0.69 to 0.93). Screening models using multiple markers for early detection of late-onset preeclampsia in low-risk pregnancy. 2018;31(21):2789-2806. Physicians shall report the Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code that describes the procedure performed to the greatest specificity When you-re reporting 59025, you-d better be sure you-ve got supporting documentation--and the supporting diagnosis to justify this code. The rate of perinatal death is reduced by as much as 29 % when umbilical artery Doppler velocimetry is added to standard antepartum testing in the setting of fetal growth restriction". Sonographic and histopathological results were evaluated. Eur J Obstet Gynecol Reprod Biol. Only1 randomized study examined the clinical impact of uterine artery blood flow; in that study, both uterine artery and umbilical artery blood flow were measured. While IMA, LFT and RFT were significantly increased in the PE group compared with the control group, albumin and CBC were significantly lower in the PE group. 1994;170:625-634. Omtzigt AM, Reuwer PJ, Bruinse HW. Routine outpatient E/M services provided within 42 days following delivery. Am J Obstet Gynecol. Together, these 3 biochemical markers are intended to contribute to accurate prediction of risk for early onset preeclampsia. The clinical utility of these tests remains unclear. Tyrrell SN, Lilford RJ, Macdonald HN, et al. A total of 145 women were left for analysis after exclusions; 14 developed PE, 23 pregnancy-induced hypertension (PIH), 64 SGA of less than fifth centile, 118 SGA of less than 10th centile and 3 stillbirth. PDF Reimbursement Rate For Cpt Code 59000 - git.dstv.com Don't Overlook ICD-9
2014;14:35. 30. National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), to reduce improper payments for Part B claims. SGA of less than fifth centile was significantly associated with low PlGF (p< 0.001 ; DR 57 %, AUC 0.73, 95 % CI: 0.65 to 0.80). In: The Cochrane Library, Issue 1, 2003. Key concept: The most important factor is that the patient marks the fetal movements. Women who developed PE had significantly higher mean sFlt-1 and endoglin levels, higher sFlt-1/PlGF ratios, and lower mean PlGF levels than women who did not. Washington, DC: ACOG; November 1998. The angiogenic factors of interest include vascular endothelial growth factor (VEGF) and placental growth factor (PlGF), as well as two anti-angiogenic proteins, soluble endoglin (sEng) and the truncated form of the full-length VEGF receptor type-1 (Flt-1), known as soluble fms-like tyrosine kinase 1 (sFlt-1) However, blood and urine levels of these factors have not been proven to be clinically useful for prediction of preeclampsia remote from disease onset Maternal serum analyte testing is an important component of Down syndrome screening programs. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. J Matern Fetal Neonatal Med. Dilatation and curettage were performed for all women. Wang KG, Chen CP, Yang JM, et al. Therefore, you would not report a separate NST.Note: For a free PDF of an outpatient fetal monitoring template you can put to use in your practice, e-mail suzannel@eliresearch.com. OB GYN Reimbursement Rate Methodology White Paper. The best cut-off for predicting PE was a PMDV of greater than22.11cm/s, with sensitivity of 70 %, specificity of 75 %, positive likelihood ratio of 2.8, negative likelihood ratio of 0.4, positive predictive value (PPV) of 28 % and negative predictive value (NPV) of 95 %. Intrapartum fetal assessment. The authors concluded that ophthalmic artery Doppler is a simple, accurate and objective technique with a standalone predictive value for the development of early-onset PE equivalent to that of uterine artery Doppler evaluation. Billing Fetal Non-Stress Test (NST) 59025. Clin Perinatol. Billing is as follows: Does not require "25" modifier with the insertion code (58300) Description This policy is to provide direction on global maternity care which includes pregnancy-related antepartum care, admission to Labor and Delivery, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care until six weeks postpartum. Washington, DC: ACOG; July 1995. Prospective observational study to determine the accuracy of first-trimester serum biomarkers and uterine artery Dopplers in combination with maternal characteristics and arteriography for the prediction of women at risk of preeclampsia and other adverse pregnancy outcomes. Abnormal flow velocity waveforms have been correlated histopathologically with small-artery obliteration in placental tertiary villi and functionally with fetal hypoxia and acidosis, as well as with perinatal morbidity and mortality. Ultrasound Obstet Gynecol. UpToDate [online serial]. Salamalekis E, Loghis C, Panayotopoulos N, et al. Billing and Reimbursement - Harvard Pilgrim Health Care Cochrane Database Syst Rev. Reston, VA: ACR; 2001. Uterine artery Doppler velocimetry for the detection of adverse obstetric outcomes in patients with elevated mid-trimester beta-human chorionic gonadotrophin. 1997;24(2):79-81. A total of 7ophthalmic artery Doppler parameters, in addition to uterine artery (UtA) Doppler and clinical variables, were examined for their prognostic value with respect to PE. READER QUESTIONS :Here's What You Need to Report 59025, Stop Mixing Up Hysterectomy Codes by HighlightingWeight, Removal, Severing these ligaments clues you into whether ob-gyn removed the ovaries. Each component is assigned2 points, resulting in a score ranging from 0 to 10, with scores from 8 to 10 considered normal, 6 considered borderline, and below 6 considered problematic. Serum levels of sFlt-1, PlGF and endoglin were measured prospectively at 4-week intervals (from gestational weeks 12 to 36) in 17 women with primary APS (PAPS), 18 women with secondary APS (SAPS), and 23 women with SLE. Per ACOG coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614).