Maternity Obstetrical Care Medical Billing & Coding Guide For 2022

Coding and billing for maternity obstetrical care is quite a bit different from other sections of the American Medical Association Current Procedural Terminology (CPT). Maternity care services typically include antepartum care, delivery services, as well as postpartum care. Depending on the patient’s circumstances and insurance carrier, the provider can either:

• Submit all rendered services for the entire nine months of services on one CMS-1500 claim form.
• Submit claims based on an itemization of maternity care services.

The Global Obstetrical PackageWhen discussing maternity obstetrical care medical billing, it is crucial to understand the Global Obstetrical Package.
Most insurance carriers like Blue Cross Blue Shield, United Healthcare, and Aetna reimburses providers based on the global maternity codes for services provided during the maternity period for uncomplicated pregnancies.
Currently, global obstetrical care is defined by the AMA CPT as “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” (Source: AMA CPT codebook 2022, page 440.)
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.
When billing for the global obstetrical package code, all services must be provided by one obstetrician, one midwife, or the same physician group practice provides all of the patient’s routine obstetric care, which includes the antepartum care, delivery, and postpartum care.
Here a “physician group practice” is defined as a clinic or obstetric clinic that is under the same tax ID number. 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.
Individual Evaluation and Management (E&M) codes should not be billed to report maternity visits unless the patient presents for issues outside the global package.
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.
Services Bundled with the Global Obstetrical PackageA 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: Care given from conception, up to (not including) the delivery of the fetus.
• Intrapartum care: Inpatient care of the passage of the fetus and placenta from the womb.
• Postpartum care: Care of the mother after delivery of the fetus.

Antepartum CareAntepartum care comprises the initial prenatal history and examination, as well as subsequent prenatal history and physical examination. This includes:

• All routine prenatal visits until delivery ( ≈ 13 encounters with patient)
  • Monthly visits up to 28 weeks of gestation
  • Biweekly visits up to 36 weeks of gestation
  • Weekly visits from 36 weeks until delivery
• Recording of weight, blood pressures and fetal heart tones
• Routine chemical urinalysis (CPT codes 81000 and 81002)
• Education on breast feeding, lactation and pregnancy (Medicaid patients)
• Exercise consultation or nutrition counseling during pregnancy

IMPORTANT: Any other unrelated visits or services within this time period should be coded separately.
Intrapartum Care AKA Labor & DeliveryLabor and delivery include:

• Admission to the hospital including history and physical
• Inpatient evaluation and management (E/M) services provided within 24 hours of delivery
• Management and fetal monitoring of uncomplicated labor
• Administration/induction of intravenous oxytocin (performed by provider not anesthesiologist)
• Insertion of cervical dilator on same date as delivery, placement catheterization or catheter insertion, artificial rupture of membranes
• Vaginal, cesarean section delivery, delivery of placenta only (the operative report)

NOTE: For any medical complications of pregnancy, see the above section “Services Bundled into Global Obstetrical Package.”
Postpartum CarePostpartum care includes the following:

• Uncomplicated inpatient visits following delivery
• Repair of first- or second-degree lacerations (for lacerations of the third or fourth degree, see “Services Bundled into Global Obstetrical Package”)
• Simple removal of cerclage (not under anesthesia)
• Routine outpatient E/M services that are provided within 6 weeks of delivery (check insurance guidelines for exact postpartum period)
• Discussion of contraception prior to discharge
• Outpatient postpartum care – Comprehensive office visit
• Educational services, such as breastfeeding, lactation, and basic newborn care
• Uncomplicated treatments and care of nipple problems and/or infection

IMPORTANT: All of the above should be billed using one CPT code. Separate CPT codes should not be reimbursed as part of the global package.

Services Excluded from the Global Obstetrical PackageCertain maternity obstetrical care procedures are either highly complex and/or not required by every patient. As such, including these procedures in the Global Package would not be appropriate for most patients and providers.  The American College of Obstetricians and Gynecologists (ACOG) has developed a list of procedures that are excluded from the global package. 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.

• Initial E/M to diagnose pregnancy if antepartum record is not initiated at this confirmatory visit
  • This confirmatory visit (amenorrhea) would be supported in conjunction with the use of ICD-10-CM diagnosis code Z32.01.
  • This is usually done during the first 12 weeks before the ACOG antepartum note is started. Use CPT Category II code 0500F.
• Laboratory tests (excluding routine chemical urinalysis)
  • Examples include CBC, liver functions, HIV testing, Blood glucose testing, sexually transmitted disease screening, and antibody screening for Rubella or Hepatitis, etc.
• Maternal or fetal echography procedures
• Obstetric ultrasound, NST, or fetal biophysical profile
  • Depending on the insurance carrier, all subsequent ultrasounds after the first three are considered bundled
• Cerclage, or the insertion of a cervical dilator more than 24 hours from admission.
• External cephalic version (turning of the baby due to malposition)
• Amniocentesis (any method)
• Amnioinfusion
• Chorionic villus sampling (CVS)
• Fetal contraction stress test
• E/M services for management of conditions unrelated to the pregnancy during antepartum or postpartum care. The diagnosis should support these services.
  • Examples include cardiac problems, neurological problems, diabetes, hypertension, hyperemesis, preterm labor, bronchitis, asthma, and urinary tract infection
  • NOTE: These encounters could be office visits, clinic visits, emergency room, or inpatient admission/observation.
• Inpatient E/M services provided more than 24 hours before delivery
• Surgical Procedures during pregnancy
  • Examples include urinary system, nervous system, cardiovascular, etc.
• Laceration repair of a third- or fourth-degree laceration at the time of delivery
  • Per ACOG coding guidelines, this should be reported using modifier 22 of the CPT code used to bill.
• Contraceptive management services (insertions)

Split Care Performed/Itemization BillingSome 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:

• The patient has received part of her antenatal care somewhere else (e.g. from another group practice).
• The patient leaves her care with your group practice before the global OB care is complete.
• Patient receives care from a midwife but later requires MD-level care.
• The patient has a change of insurer during her pregnancy.

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:

• Antepartum care only. The following CPT codes apply based on how many visits a patient had with your practice:
  • 59425: Antepartum care only, 4-6 visits
  • 59426: Antepartum care only, 7 or more visits; E/M visit if only providing 1-3 visits
• Delivery only: CPT codes 59409, 59514, 59612, and 59620
• Postpartum care only: CPT code 59430

Diagnosis Codes for Deliveries and Related Services

• Reporting Routine Prenatal Visits: routine prenatal visits are reported with a code from category Z34.- It should always be the first-listed diagnosis code unless the patient has other medical conditions affecting the pregnancy. Note that Z34.- codes should never be reported with an O code.
• Outcome of Delivery: should be included when a delivery has occurred (ICD-10-CM Z37.-).
• Normal Delivery (ICD-10-CM O80): only for full-term normal delivery and delivers a single, healthy infant. Additionally, there are no complications in the antepartum period, during the delivery, or in the postpartum period during the delivery encounter.
  • If O80 is not appropriate, the primary diagnosis should reflect the main circumstances or complications of the delivery.
  • If the patient is admitted with condition resulting in cesarean, then that is the primary diagnosis.
  • If admitted for other reason, the admitting diagnosis is primary for admission and reason for cesarean linked to delivery.
  • If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis.
• O Codes: An O code from ICD-10-CM Chapter 15 – “Pregnancy, Childbirth & the Puerperium” should always be reported for the delivery when the patient has experienced any current complication in the antepartum period, during the delivery, or in the postpartum period.
• All conditions treated or monitored can be reported (e.g., gestation diabetes, pre-eclampsia, prior C-section, anemia, GBS, etc.)

Who Is Eligible to Provide Patient Care?The following is a comprehensive list of eligible providers of patient care (with the exception of residents, who are not billable providers):

• Obstetrician, Maternal Fetal Specialist, Fellow
• Certified Nurse Midwife (CNM)
• Nurse Practitioner Midwife (NPM)
• Certified Professional Midwife (CPM)

ModifiersDepending 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).