Policy No: 107
Originally Created: 03/01/2012
Section: Medicine
Last Reviewed: 10/01/2024
Last Revised: 10/01/2024
Approved: 10/10/2024
Effective: 11/01/2024
Policy Applies To: Group and Individual & Medicare Advantage

This policy applies only to physicians and other qualified health care professionals.

Included antepartum services:

• Monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery
• Initial and subsequent history and physical examinations

• Recording of weight, blood pressures, fetal heart tones, and routine chemical urinalysis

Please refer to Modifier 22 instructions below and/or Reimbursement Policy Mod 111 - Modifier 22; Increased Procedural Services

• Admission to L&D, update of history & physical, or any E&M service on the calendar day prior to delivery and/or calendar day of delivery
• Management of labor including fetal monitoring
• Placement of internal fetal and/or uterine monitors
• Catheterization or catheter insertion
• Preparation of abdomen and/or the perineum
• Vaginal delivery with or without forceps or vacuum extraction
• Delivery of the placenta, any method
• Episiotomy and repair/suturing of lacerations
• Cesarean section delivery
• Injection of local anesthesia
• Administration of drugs for induction of labor such as but not limited to: intravenous oxytocin (96365-96367)
• Exploration of uterus and/or uterine repair
• Placement of a hemostatic pack or agent

• Simple removal of cerclage (not under anesthesia)

• Recovery room visit
• Uncomplicated inpatient hospital postpartum visits
• Uncomplicated outpatient visits for 45 days postpartum in any setting
• Discussion of contraception

• Routine lactation services

Services provided in uncomplicated maternity cases including antepartum care, delivery and postpartum care.

Beginning on the date the prenatal record is initiated and extending through postpartum period (45 days postpartum).

The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule assigns maternity procedure codes a global days indicator of MMM and does not identify the number of days for a Maternity global period. Our health plan has established maternity global periods.

Our health plan reimburses global maternity services provided during the maternity period for a member’s pregnancy.

The following antepartum Current Procedural Terminology (CPT®) codes may be eligible for reimbursement:

• CPT 59425 - Antepartum care only, complicated, or uncomplicated; 4-6 visits

• CPT 59426 - Antepartum care only, complicated, or uncomplicated; 7 or more visits

Antepartum care includes initial history and physical, subsequent physical exams, recording of weight, blood pressure and fetal heart tones and routine urinalysis.

Routine antepartum care includes a minimum of four (4) prenatal visits. Note: For management of pregnancy complications requiring more than thirteen (13) prenatal visits, report the visit separately. According to The American Congress of Obstetricians and Gynceologist (ACOG), the normal prenatal visit interval frequency consists of the following: Monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery.

Fewer than four (4) prenatal visits do not qualify for global reimbursement. Each visit should be billed with an Evaluation & Management (E&M) code.

If the prenatal record is initiated during the confirmatory visit then the confirmatory visit becomes part of the global OB package and is not reported separately. Services to diagnose the pregnancy may be separately reimbursable, with the appropriate level of E/M service, when the pregnancy is confirmed during a problem-oriented or preventive care visit.

Other visits or services that are stated or documented in the patient's medical record by the attending practitioner as being unrelated to the pregnancy, but rendered to the patient during the maternity period, may be eligible for separate reimbursement using E&M codes or medical service codes. These could include, but are not limited to, management of cardiac problems, pneumonia, chronic hypertension, etc. that are unrelated to the pregnancy. Services rendered due to an unrelated condition of the pregnancy, but warrants additional management of the patient's maternity care, is eligible for separate reimbursement.

Surgical care during the antepartum period may be eligible for separate reimbursement. This could include adnexal mass, hernia repair, appendicitis, etc.

Ongoing services after evaluation of pregnant patient not found to be in active labor that are not associated with management of OB complications are not separately reimbursable from global OB services. These could include, but are not limited to, latent phase of labor without OB complications, transfer of care due to pain tolerance.

During uncomplicated active labor management, professional (physicians and other qualified healthcare professionals) services (see definitions above) are considered inclusive of the global OB services and are not separately reimbursable.

If a transfer of care occurs during active labor (including those resulting in a change in physical location, i.e., birthing center to hospital or hospital/hospital transfer), the providers are responsible for coordinating billing to ensure correct coding. Unbundled, overlapping, or duplicate services are not reimbursable. Prolonged services involving indefinite periods of time such as labor and delivery management are not separately reimbursable per ACOG coding guidelines. Examples of prolonged services include add-on codes 99354, 99355, 99356, 99357, 99358, 99359, 99415 and 99416. Please note that any maternity delivery code includes uncomplicated labor management.

Delivery only services codes include:

• CPT 59409 - Vaginal delivery only, with or without episiotomy and/or forceps
• CPT 59514 - Cesarean delivery only
• CPT 59612 - Vaginal delivery only, after previous Cesarean delivery (VBAC), with or without episiotomy and/or forceps

• CPT 59620 - Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery

Delivery only services include, but are not limited to admission to hospital, admission history and physical examination, management of uncomplicated labor including fetal monitoring, vaginal or cesarean delivery, delivery of placenta, simple removal of cerclage and routine inpatient care immediately following delivery on the same calendar day of delivery.

CPT code 59200 (Insertion of cervical dilator) one day or more prior to the delivery, by a physician and external cephalic version, amniocenteses and cervical cerclage are eligible for separate reimbursement.

Delivery only services that are not eligible for separate reimbursement include:

• Induction of labor (unless the obstetrician personally starts the IV and sits with the patient during the infusion)

The following postpartum services code may be eligible for reimbursement:

CPT 59430 - Postpartum care only

Postpartum care only services include postpartum home or office visits following vaginal or cesarean section delivery, discussion of contraception, routine lactation services and suture removal.

The following services are examples of postpartum care that may be separately reimbursed:

• complications related to lactation
• intrauterine device (IUD) insertion and

• medical management of postpartum depression PPD.

Antenatal care codes, delivery services codes and/or postpartum care codes that may be separately reimbursable are:

• Consults made during active labor management, delivery and postpartum,
• Administration of general or regional anesthesia during active labor, delivery and postpartum,
• Another physician/other health care professional provider assumes OB care, either by member transfer or provider referral, except during intrapartum care
• The member is delivered by another physician/other health care professional not in the same practice or when pregnancy is terminated or when the member changes insurers.

• For Commercial plans, home birth kits are eligible for reimbursement up to 1 kit per pregnancy, billed on the mother’s claim with procedure code S8415, Supplies for Home Delivery of Infant. Allowable supplies included in the reimbursement of the home birth kit are not separately reimbursable and must be medically necessary for home delivery.

The following global maternity codes may be appropriate when billed by any member of the same maternity practice group that provides the antepartum, delivery and postpartum care:

• CPT 59400 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care
• CPT 59510 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care
• CPT 59610 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

• CPT 59618 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery

Services included in the global maternity reimbursement will not be reimbursed separately, for example:

• Pregnancy related E&M services provided 280 days prior to date of delivery and up to 45 days after date of delivery.
• Routine lactation services.
• Home postpartum visits are not eligible for separate reimbursement.
• All E&M codes are subject to global maternity period coding guidelines.

• CPT 99464 - Attendance at delivery (when requested by the delivering physician or other health care professional) and initial stabilization of the newborn, is not separately reimbursable with maternity codes, including maternity delivery codes, when billed by the same provider.

Treatment/Services (unrelated to the pregnancy) performed by the provider billing the global maternity care should be reported separately with the appropriate inpatient or outpatient E&M code using the condition unrelated to pregnancy as the primary diagnosis code.

Procedures should be reported with the CPT/Healthcare Common Procedure Coding System (HCPCS) code that describes the services performed to the greatest specificity possible and only if all services described by that code are performed. Unbundling occurs when multiple codes are used to report a procedure covered by a single comprehensive CPT/HCPCS code.

Global billing for multiple gestations should include one global procedure code and a "delivery only" code for each subsequent delivery.

• The specific codes submitted will depend on the method of delivery and number of infants delivered.
• The code submitted for the secondary delivery should include a modifier 51, and will be reimbursed according to multiple procedure guidelines. An exception to this rule exists when all infants are delivered via Cesarean. See the summarized billing examples below. This summary addresses only scenarios where a global procedure code is appropriate:

Modifier 22 is appropriate when any one of the following are met:

• Cesarean delivery of twins is performed, report code 59510 only.
• Delivery of a singleton requires substantial additional work report delivery only code.

• Entire global period (antenatal, labor/delivery, postpartum) is complicated and necessitates greater effort than typically required, use global code.

Repair of third- or fourth-degree lacerations at the time of delivery may be reported, by using a CPT code from the Integumentary section (e.g., 12041-12047 or 13131-13133), when billing a global maternity code. Or, if billing the delivery only code, modifier 22 may be added to report the repair.

To be considered for increased reimbursement, documentation from the patient's record supporting the substantially greater effort performed by the provider must be submitted with the claim. Documenting the extent of the patient's illness or comorbid conditions is not enough to demonstrate the additional work. The documentation must describe additional work performed.

Please refer to Mod 111 – Modifier 22; Increased Procedural Services

Home/birthing center deliveries and postpartum services are subject to this reimbursement policy in the same manner as services performed by physicians and other health care professionals who deliver in the hospital setting.

American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care

The American Congress of Obstetricians and Gynecologists (ACOG), OB/GYN Coding Manual: Components of Correct Procedural Coding

Global Days

Modifier 51 and Multiple Procedure Logic

Modifier 22; Increased Procedural Services