Coding and Billing Guidelines for Maternity Services

Section: Coding Guidelines

Effective Date: October 31, 2019

Revision Effective Date: February 15, 2024

Last Reviewed: February 15, 2024

Archived Date: February 15, 2024

Applies To: Commercial and Medicaid Expansion

This policy has been archived. Click on the Archive tab above for the archived version.

Section: Coding Guidelines

Effective Date: October 31, 2019

Revision Effective Date: February 15, 2024

Last Reviewed: February 15, 2024

Archived Date: February 15, 2024

Applies To: Commercial and Medicaid Expansion

This document provides coding and billing guidelines for maternity services. For policy rules refer to the Global Maternity Policy NDRP-GC-021.

Coding & Billing Guidelines

Global Maternity

A global charge should only be billed when all maternity-related services are provided by the same physician/qualified healthcare practitioner (QHP) or another physician/QHP’s practicing at the same location reporting under the same Federal Tax Identification Number (TIN). The global maternity code is reported after the delivery.

Prenatal Delivery and/or Postpartum Services Billed Separately

Maternity Service

Number of Visits

Coding & Billing

Antepartum Care Only

1 to 3 visits

Use the appropriate E&M code(s)

Antepartum Care Only

4 to 6 visits

Use CPT code 59425 and one (1) unit

Antepartum Care Only

7 or more visits

Use CPT code 59426 and one (1) unit

Postpartum Care Only

Use CPT 59430

In the event a physician/QHP in a different practice provides the prenatal and/or postpartum care but does not perform the delivery, the delivering physician/QHP may file using the antepartum/postpartum care-only codes. The applicable code may be reported based on the above criteria.

Billing Scenarios and Additional Information

Billing Scenarios

Scenario 1: Maternity care provided by two different physicians in two different unaffiliated groups

Dr. Blue provides only antepartum and/or postpartum patient care and does not perform the delivery. Therefore, Dr. Blue should file the appropriate CPT code(s) for only the antepartum/postpartum care. Dr. Cross, who is unaffiliated with Dr. Blue’s practice, performs the delivery. Therefore, Dr. Cross should file the appropriate CPT code for only the delivery. In this scenario, the prenatal care, labor and delivery, and post-delivery care were provided by two different physicians in two different unaffiliated groups. A global CPT code is not applicable and should not be filed by either physician.

Scenario 2: Maternity care provided by two different physicians practicing at the same location (group)

When two different physicians are practicing at the same location, and both are providing the maternity care (for example, Dr. Blue provides antepartum & postpartum care, and Dr. Cross performs the delivery), a single claim should be filed with the appropriate global maternity CPT code. Two different claims should not be filed since Dr. Blue and Dr. Cross are rendering the maternity care and practice at the same location.

Scenario 3: Sterilization performed in addition to providing all services for a cesarean delivery

Dr. Blue provides all services for a cesarean delivery. In addition to providing all services for a cesarean delivery, Dr. Blue performs a sterilization procedure immediately following the delivery. Dr. Blue’s office should submit a claim with the global maternity code (cesarean delivery) on one line and the appropriate CPT code(s) for sterilization services provided post-cesarean delivery within the same maternity stay.

Scenario 4: Repair of fourth laceration only; physician performs no other maternity-related services

Dr. Blue provides all services for a vaginal delivery. Dr. Cross repairs a fourth-degree laceration to the cervix during the delivery. The claim for Dr. Blue’s services should be filed first and reflect the global maternity services (vaginal delivery). Dr. Cross’s services for the laceration repair during the delivery should be billed separately. Third and fourth-degree laceration repairs are considered separately identifiable services.

Additional Information

Ultrasound During Pregnancy

Ultrasound performed during routine screening during pregnancy is considered an integral part of patient care during pregnancy. Reimbursement is included in the global maternity care fee. Ultrasound during pregnancy is reimbursed separately only when used for the diagnosis or treatment of a specified medical condition(s).

Unrelated to Pregnancy

(Performed by the physician rendering global maternity care)

Services unrelated to pregnancy, but performed by the physician rendering global maternity care, should be documented and reported separately with the appropriate inpatient or outpatient E/M code with modifier 24 appended, using the condition unrelated to pregnancy as the primary diagnosis code. Additionally, the diagnosis should reflect the separately identifiable service.

Surgical Complications

Services related to surgical complications should be filed separately.

Referral to Perinatologist

When a member is referred to and evaluated by a perinatologist, the perinatologist should bill an E/M consultation code with the problem diagnosis that necessitated the referral. Maternity health status codes should not be used, as they may cause the visit to be attributed to global maternity care.

Complications of Pregnancy

Complications of pregnancy per member certificate language are medical conditions with diagnoses that are distinct from pregnancy, but are adversely affected or caused by pregnancy, resulting in the mother’s life being in jeopardy or making the birth of a viable infant impossible, and which require the mother to be treated prior to the full term of pregnancy.

PrenatalPlus+ Program

The program gives mothers-to-be helpful tools and information, so they can make healthy decisions throughout their pregnancy. A case manager from BCBSND will be assigned for high-risk pregnancies to help navigate the health care system and increase the likelihood of a healthy pregnancy. For more information contact us at 844-363-8457.

Provider Resources

Physicians can reference the following resources for additional information related to filing claims for maternity care: The Current Procedural Terminology® manual

Limitations & Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

History

Date

Updates

2/15/2024

Information was moved from this document and to the NDRP-GC-021 Global Maternity reimbursement policy. Archiving Guideline.

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Coding and Billing Guidelines for Maternity Services

This policy has been archived. Click on the Archive tab above for the archived version.

Coding & Billing Guidelines

Global Maternity

Prenatal Delivery and/or Postpartum Services Billed Separately

Billing Scenarios and Additional Information

Limitations & Exclusions

History