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:
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 CareAntepartum care comprises the initial prenatal history and examination, as well as subsequent prenatal history and physical examination. This includes:
Intrapartum Care AKA Labor & DeliveryLabor and delivery include:
Postpartum CarePostpartum care includes the following:
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.
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:
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:
Diagnosis Codes for Deliveries and Related Services
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):
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).