Global Maternity

Policy ID: NDRP-GC-021

Section: General Coding

Effective Date: October 31, 2019

Revision Effective Date: May 31, 2024

Last Reviewed: March 27, 2024

Applies To: Commercial and Medicaid Expansion

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.

Descriptions

Antepartum

Period from confirmation of pregnancy to delivery of the baby.

Global Care

A single code and related reimbursement for all care usually associated with a procedure; the packaging is based on three phases of a surgical procedure: preoperative evaluation, the intraoperative procedure, and postoperative care for either zero, ten, or ninety days.

Postpartum

Period from the termination of labor to complete reduction of the uterus to its normal nonpregnant size and state, usually about forty-two days.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Policy

Providers may file global maternity care when they provide prenatal care, labor and delivery and postpartum care. 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.

Services not included in Global Maternity Care:

An initial visit, confirming the pregnancy, is not a part of global maternity care services.
Antepartum services such as laboratory tests (excluding dipstick urinalysis), diagnostic ultrasound, amniocentesis, cordocentesis, chorionic villus sampling, fetal stress test, and fetal non-stress test are not considered part of global maternity services and should be billed separately.

Cesarean Section with an Assistant at Surgery

Only a non-global cesarean section delivery code (without antepartum or postpartum components) is a reimbursable service when submitted with an appropriate assistant surgeon modifier.

Prenatal, Delivery and/or Postpartum Services Billed Separately

It would be appropriate for the provider to file prenatal, delivery and/or postpartum services separately if:

The member’s coverage started after the onset of pregnancy
The coverage terminates prior to delivery
The pregnancy does not result in delivery
The member’s coverage offers a cost share waiver for prenatal care.
Another provider in a different practice assumes care of the member prior to completion of global services
During the member’s pregnancy, there was a change in the member’s benefit package or certificate number due to an employer change only

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.

Multiple Births Billing Guidelines

The below table outlines appropriate billing for multiple births.

Multiple Birth Guidelines

Newborn(s)

Procedures Codes

Coding & Reimbursement

Vaginal delivery

First Newborn

59400

59409

59410

59610

59612

59614

Global vaginal delivery

Vaginal delivery only

Vaginal delivery only; including postpartum (PP)

Global vaginal delivery, after previous cesarean delivery (VBAC)

VBAC delivery only

VBAC; including PP

Use the appropriate vaginal delivery code for the first newborn
Reimbursed at 100% of the allowable charge

Subsequent Newborn(s)

59409

59612

Vaginal delivery only

VBAC delivery only

Use the appropriate vaginal delivery-only code with modifier 59 appended
Reimbursed at 50% of the allowable charge for each newborn

Note: If more than one subsequent baby is delivered, the total number of subsequent newborns should be indicated in the unit’s field.

Cesarean (C-section)

First Newborn

59510

59514

59515

59618

59620

59622

Global C-section

C-section delivery only

C-section delivery only; including PP

Global C-section after VBAC

C-section delivery only after VBAC

C-section delivery only after VBAC; including PP

Use the appropriate Cesarean delivery code for the first newborn
Reimbursed at 100% of the allowable charge regardless of the subsequent newborns

Subsequent Newborn(s)

59514

59620

C-section delivery only

C-section delivery only after VBAC

Use the appropriate Cesarean delivery-only code with modifier 59 appended

Note: Report only once regardless of the number of babies delivered.

Vaginal delivery followed by Cesarean delivery

First Newborn

(Vaginal)

59409

59612

Vaginal delivery only

VBAC delivery only

Use the appropriate vaginal delivery-only code with modifier 59 appended
Reimbursed at 50% of the allowable charge

Subsequent Newborn(s)

(C-section)

59510

59514

59515

59618

59620

59622

Global C-section

C-section delivery only

C-section delivery only; including PP

Global C-section after VBAC

C-section delivery only after VBAC

C-section delivery only after VBAC; including PP

For the subsequent newborn(s) delivered by Cesarean, use the appropriate C-section delivery code
The primary procedure will be reimbursed at 100% of the allowable charge and secondary procedure will be reimbursed at 50% of the allowable charge

Note: If more than one subsequent baby is delivered via C-section report only once regardless of the number of babies delivered.

Services Unrelated to Pregnancy

Services unrelated to pregnancy but performed by the provider rendering global maternity care should be documented and reported separately with the appropriate inpatient or outpatient Evaluation and Management (E/M) code, appropriate modifier appended, and using the condition unrelated to pregnancy as the primary diagnosis code.

Referral to Perinatologist

When a member is referred to and evaluated by a perinatologist, that perinatologist should bill an E/M 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.

Quality Reporting

In support of quality tracking and in accordance with HEDIS guidelines, we encourage that claims (in addition to the global billing claim) be submitted for the following:

Date of first prenatal visit: Submit a claim reflecting the actual date of the first visit for prenatal care. Use CPT Category II code 0500F (Initial prenatal care visit) or 0501F (Prenatal flow sheet documented in medical record by first prenatal visit)
Date of postpartum visit: The postpartum visit should occur 4-6 weeks after delivery. Submit a claim with the actual date the postpartum service was rendered. Use CPT Category II Code 0503F (Postpartum care visit).
Date of last menstrual period (LMP): Box 14 of the CMS 1500 Claim Form

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 maternity care over the course of the pregnancy (for example, Dr. Blue provides antepartum & postpartum care, and Dr. Cross performs the delivery):

Global Billing Option – Only a single claim may be filed with the appropriate global maternity CPT code.
Separate Billing Option – Separate services may be filed based on above policy allowance; however, a global code may not be billed by either provider.
- Dr. Blue would bill for only the antepartum and postpartum care.
- Dr. Cross will bill for only the delivery rendering.

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.

Cross References

The Current Procedural Terminology (CPT) Manual

History

Date

Updates

4/12/2021

Added Cesarean Section with an Assistant at Surgery direction

8/31/2021

Updated to new format

7/1/2022

Policy reviewed

6/26/2023

Policy annual review completed

3/27/2024

Coding and Billing Guideline information has been consolidated into this policy. Policy application section has been added to indicate the editing is based the date of service. No policy claim application changes occurred.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.

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Medical Policies Quick Search

Global Maternity

Description

Descriptions

Policy Application

Policy

Cesarean Section with an Assistant at Surgery

Prenatal, Delivery and/or Postpartum Services Billed Separately

Multiple Births Billing Guidelines

Multiple Birth Guidelines

Vaginal delivery

Cesarean (C-section)

Vaginal delivery followed by Cesarean delivery

Services Unrelated to Pregnancy

Referral to Perinatologist

Quality Reporting

Billing Scenarios and Additional Information

Billing Scenarios

Additional Information

Limitations & Exclusions

Cross References

History

Disclaimer