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
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Antepartum
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Period from confirmation of pregnancy to delivery of the baby.
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Global Care
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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.
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Postpartum
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Period from the termination of labor to complete reduction of the uterus to its normal nonpregnant size and state, usually about forty-two days.
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Policy
The following antepartum services are not considered a part of global maternity care such as laboratory tests (excluding dipstick urinalysis), diagnostic ultrasound, amniocentesis, cordocentesis, chorionic villus sampling, fetal stress test, and fetal non-stress test and are eligible to be reimbursed separately. Normally, a provider should file global maternity care when they provide prenatal care, labor and delivery and postpartum care.
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
- 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
Multiple Births Billing Guidelines
Vaginal deliveries only
- Baby A: File the appropriate “global vaginal delivery” code. (Reimbursed at 100% of the allowable.)
- Babies B and beyond: File appropriate “vaginal delivery only” code with modifier 59 appended. If more than one subsequent baby is delivered, the total number of babies B and beyond should be indicated in the units field. (Reimbursed at 50% of the allowable each for Babies B and beyond.)
- If antepartum and/or postpartum care were not provided, then report only the appropriate “vaginal delivery only” code, reflecting the total number of deliveries in the units fields for Babies A and beyond (Reimbursed at 50% of the allowable for Babies B and beyond.)
- If antepartum care was not provided but postpartum care following hospital discharge was provided, report appropriate code for “vaginal delivery only including postpartum care” for Baby A. Report the appropriate “vaginal delivery only” code for Babies B and beyond with modifier 59 appended. If more than one subsequent baby is delivered, the total number of babies B and beyond should be indicated in the units field. (Reimbursed at 50% of the allowable each for Babies B and beyond.)
Cesarean delivery only
- Baby A and beyond: File only once for appropriate “global Cesarean delivery” code. (Reimbursed at 100% of the allowable.)
- If antepartum and postpartum care were not provided, then report only once the appropriate “Cesarean delivery only” code.
- If antepartum care was not provided but postpartum care following hospital discharge was provided, then report only once the appropriate “Cesarean delivery only; including postpartum care” code.
- “Global Cesarean delivery,” “Cesarean delivery only,” and “Cesarean delivery only; including postpartum care” codes should be reported only once regardless of the number of babies delivered.
Vaginal delivery, followed by Cesarean delivery
- Baby A: File appropriate “vaginal delivery only” code with modifier 59 appended. (Reimbursed at 50% of allowable.)
- Baby B and beyond: File appropriate “global Cesarean delivery” or “Cesarean delivery only” code once. (Reimbursed at 100% of allowable.) When global care was also provided, the global service is applied to the Cesarean delivery as the intrapartum work and postpartum care is more pertinent to a Cesarean delivery than a vaginal delivery.
- If antepartum care was not provided, but postpartum care following hospital discharge was provided, code the appropriate code for “vaginal delivery only” for Baby A with modifier 59 appended. (Reimbursed at 50% of allowable.) Report the appropriate “Cesarean delivery only; including postpartum care” code once for Babies B and beyond. (Reimbursed at 100% of allowable.)
- “Global Cesarean delivery,” “Cesarean delivery only,” and “Cesarean delivery only; including postpartum care” codes should be reported 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 code, 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 Evaluation and Management 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.
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
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, 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
History
Date
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Updates
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4/12/2021
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Added Cesarean Section with an Assistant at Surgery direction
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8/31/2021
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Updated to new format
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7/1/2022
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Policy reviewed
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6/26/2023
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Policy annual review completed
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