Policy No: 107
Originally Created: 03/01/2012
Last Reviewed: 03/01/2019
This policy applies only to physicians and other qualified health care professionals
The following antepartum Current Procedural Terminology (CPT®) codes may be eligible for reimbursement:
- CPT 59425 - Antepartum care only, complicated or uncomplicated; 4-6 visits
- CPT 59426 - Antepartum care only, complicated or uncomplicated; 7 or more visits
Antepartum care includes initial history and physical, subsequent physical exams, recording of weight, blood pressure and fetal heart tones and routine urinalysis.
Routine antepartum care includes a minimum of four (4) and a maximum of fifteen (15) prenatal visits. According to ACOG, the normal prenatal visit interval frequency consists of the following: Monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. For management of pregnancy complications requiring more than fifteen (15) prenatal visits, please refer to Modifier 22 reimbursement policy.
Fewer than four (4) prenatal visits do not qualify for global reimbursement. Each visit should be billed with an Evaluation & Management (E&M) code.
If the prenatal record is initiated during the confirmatory visit then the confirmatory visit becomes part of the global OB package and is not reported separately. If the prental record is not initiated during the confirmatory visit, then the confirmatory visit may be separately reported.
The initial prenatal visit including history and physical exam is not separately reimbursable from the global OB package. Once the pregnancy is confirmed, any preventive screening or exam services will be considered part of the initial or subsequent OB visit per ACOG's Guidelines for Perinatal Care.
Other visits or services that are stated or documented in the patient's medical record by the attending practitioner as being unrelated to the pregnancy, but rendered to the patient during the maternity period, may be eligible for separate reimbursement using E&M codes or medical service codes. These could include, but are not limited to, management of cardiac problems, pneumonia, chronic hypertension, etc. that are unrelated to the pregnancy. Services rendered due to an unrelated condition of the pregnancy, but warrants additional management of the patient's maternity care, is eligible for separate reimbursement.
Surgical care during the antepartum period may be eligible for separate reimbursement. This could include adnexal mass, hernia repair, appendicitis, etc.
Ongoing services after evaluation of pregnant patient not found to be in active labor that are not associated with management of OB complications are not separately reimbursable from global OB services. These could include, but are not limited to, latent phase of labor without OB complications, transfer of care due to pain tolerance, etc.
During uncomplicated active labor management, professional (physicians and other qualified healthcare professionals) services that are considered inclusive of the global OB services include, but are not limited to:
- Admission to labor and delivery, update of history & physical, or any E&M service on the calendar day prior to delivery and/or calendar day of delivery
- Management of uncomplicated labor including fetal monitoring
- Placement of internal fetal and/or uterine monitors
- Catheterization or catheter insertion
- Preparation of the perineum with antiseptic solution
If a transfer of care occurs during active labor (including those resulting in a change in physical location, i.e. birthing center to hospital or hospital/hospital transfer), the providers are responsible for coordinating billing to ensure correct coding. Unbundled, overlapping or duplicate services are not reimbursable. Prolonged services involving indefinite periods of time such as labor and delivery management are not separately reimbursable per ACOG coding guidelines. Examples of prolonged services include add-on codes 99354, 99355, 99356, 99357, 99358, 99359, 99415 and 99416. Please note that any maternity delivery code includes uncomplicated labor management.
Delivery only services codes include:
- CPT 59409 - Vaginal delivery only, with or without episiotomy and/or forceps
- CPT 59514 - Cesarean delivery only
- CPT 59612 - Vaginal delivery only, after previous Cesarean delivery (VBAC), with or without episiotomy and/or forceps
- CPT 59620 - Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery
Delivery only services include admission to hospital, admission history and physical examination, management of uncomplicated labor including fetal monitroing, vaginal or cesarean delivery, delivery of placenta, simple removal of cerclage and routine inpatient care immediately following delivery on the same calendar day of delivery.
Delivery only services that are not eligible for separate reimbursement include:
- Induction of labor (unless the obstetrician personally starts the IV and sits with the patient during the infusion)
CPT code 59200 (Insertion of cervical dilator) on the same day as the delivery.
External cephalic version, amniocentesis and cervical cerclage are eligible for separate reimbursement.
The following postpartum services code may be eligible for reimbursement:
- CPT 59430 - Postpartum care only
Postpartum care only services include postpartum home or office visits following vaginal or cesarean section delivery, discussion of contraception, routine lactation services and suture removal.
Postpartum care excludes, but is not limited to, complications related to lactation, intrauterine device (IUD) insertion and medical management of postpartum depression.
Antenatal care codes, delivery services codes and/or postpartum care code are separately reimbursable when:
- Consults are made during active labor management, delivery and postpartum,
- Anesthesia services are provided during active labor, delivery and postpartum,
- Another physician/other health care professional provider assumes OB care, either by member transfer or provider referral, except during intrapartum care,
- The member is delivered by another physician/other health care professional not in the same practice or when pregnancy is terminated or when the member changes insurers.
The following global maternity codes are appropriate when the same group physician/other health care professional provide the antepartum, delivery and postpartum care:
- CPT 59400 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care
- CPT 59510 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care
- CPT 59610 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery
- CPT 59618 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery
Global maternity codes are appropriate when the same group physician/other health care professional provide the antepartum, delivery and postpartum care.
Services included in the global maternity reimbursement will not be reimbursed separately, for example:
- Pregnancy related E&M services provided 270 days prior to maternity delivery and up to 45 days after maternity delivery.
- Routine lactation services
- Home postpartum visits are not eligible for separate reimbursement.
- All E&M codes are subject to global maternity period coding guidelines.
- CPT 99464 - Attendance at delivery (when requested by the delivery physicia or other health care professional) and initial stabilization of the newborn, is not separately reimbursable with maternity codes, including maternity delivery codes, when billed by the same provider.
Treatment/Services (unrelated to the pregnancy) performed by the provider billing the global maternity care should be reported separately with the appropriate inpatient or outpatient E&M code using the condition unrelated to pregnancy as the primary diagnosis code.
Procedures should be reported with the CPT/Healthcare Common Procedure Coding System (HCPCS) code that describes the services performed to the greatest specificity possible and only if all services described by that code are performed. Unbundling occurs when multiple codes are used to report a procedure covered by a single comprehensive CPT/HCPCS code.
Global billing for multiple gestations should include one global procedure code and a "delivery only" code for each subsequent delivery.
- The specific codes submitted will depend on the method of delivery and number of infants delivered.
- The code submitted for the secondary delivery should include a modifier 51, and will be reimbursed according to multiple procedure guidelines. An exception to this rule exists when all infants are delivered via Cesarean. See the summarized billing examples below. This summary addresses only scenarios where a global procedure code is appropriate:
|Twin Pregnancy, both delivered vaginally|
|Twin Pregnancy, both delivered VBAC|
|Twin Pregnancy, VBAC followed by C-section|
|1st Newborn||59612-51-59||1st delivery is considered the secondary procedure for reimbursement purposes.|
|2nd Newborn||59618||2nd delivery is considered the primary procedure for reimbursement purposes.|
|Twin Pregnancy, vaginal delivery followed by C-section|
|1st Newborn||59409-51-59||1st delivery is considered the secondary procedure for reimbursement purposes.|
|2nd Newborn||59510||2nd delivery is considered the primary procedure for reimbursement purposes.|
|Twin Pregnancy, both delivered by C-section|
|2nd Newborn||No code|
For global maternity care, modifier 22 is appropriate in addition when any one of the following are met:
- Management of pregnancy related complications (pre-eclampsia, preterm labor, bleeding, etc.) requires greater than 15 antepartum visits; including outpatient and/or inpatient hospital visits.
- Cesarean delivery is required for multiple gestations.
Cesarean delivery requires substantial additional work.
To be considered for increased reimbursement, documentation from the patient's record supporting the substantially greater effort performed by the provider must be submitted with the claim. Documenting the extent of the patient's illness or comorbid conditions is not sufficient to demonstrate the additional work. The documentation must describe additional work performed.
Please refer to Mod 111 – Modifier 22; Increased Procedural Services
Home/birthing center deliveries and postpartum services are subject to this reimbursement policy in the same manner as services performed by physicians and other health care professionals who deliver in the hospital setting.
American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care
The American Congress of Obstetricians and Gynecologists (ACOG), OB/GYN Coding Manual: Components of Correct Procedural Coding