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:
- Submit all rendered services for the entire nine months of services on one CMS-1500 claim form.
- Submit claims based on an itemization of maternity care services.
Maternity Obstetrical Care Medical Billing & Coding Guide for 2021
This article explores the key aspects of maternity obstetrical care medical billing and breaks down the important information your OB/GYN practice needs to know. We will go over:
- Different types of services rendered
- The global maternity care package: what services are included and excluded?
- The split OB packages
- Complications of pregnancy
- High-risk patients
- CPT definitions
- And much more
Finally, always be aware that individual insurance carriers provide additional information such as modifier use.
We sincerely hope that this guide will assist you in maternity obstetrical care medical billing and coding for your practice. For more details on specific services and codes, see below.
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Table of Contents
The Global Obstetrical Package
When 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 2021, 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 Package
A 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 care: Care given from conception, up to (not including) the delivery of the fetus.
- Intrapartum care: Inpatient care of the passage of the fetus and placenta from the womb.
- Postpartum care: Care of the mother after delivery of the fetus.
Antepartum care comprises the initial prenatal history and examination, as well as subsequent prenatal history and physical examination. This includes:
- All routine prenatal visits until delivery ( ≈ 13 encounters with patient)
- Monthly visits up to 28 weeks of gestation
- Biweekly visits up to 36 weeks of gestation
- Weekly visits from 36 weeks until delivery
- Recording of weight, blood pressures and fetal heart tones
- Routine chemical urinalysis (CPT codes 81000 and 81002)
- Education on breast feeding, lactation and pregnancy (Medicaid patients)
- Exercise consultation or nutrition counseling during pregnancy
IMPORTANT: Any other unrelated visits or services within this time period should be coded separately.
Intrapartum Care AKA Labor & Delivery
Labor and delivery include:
- Admission to the hospital including history and physical
- Inpatient evaluation and management (E/M) services provided within 24 hours of delivery
- Management and fetal monitoring of uncomplicated labor
- Administration/induction of intravenous oxytocin (performed by provider not anesthesiologist)
- Insertion of cervical dilator on same date as delivery, placement catheterization or catheter insertion, artificial rupture of membranes
- Vaginal, cesarean section delivery, delivery of placenta only (the operative report)
NOTE: For any medical complications of pregnancy, see the above section “Services Bundled into Global Obstetrical Package.”
Postpartum care includes the following:
- Uncomplicated inpatient visits following delivery
- Repair of first- or second-degree lacerations (for lacerations of the third or fourth degree, see “Services Bundled into Global Obstetrical Package”)
- Simple removal of cerclage (not under anesthesia)
- Routine outpatient E/M services that are provided within 6 weeks of delivery (check insurance guidelines for exact postpartum period)
- Discussion of contraception prior to discharge
- Outpatient postpartum care – Comprehensive office visit
- Educational services, such as breastfeeding, lactation, and basic newborn care
- Uncomplicated treatments and care of nipple problems and/or infection
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 Package
Certain 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.
- Initial E/M to diagnose pregnancy if antepartum record is not initiated at this confirmatory visit
- This confirmatory visit (amenorrhea) would be supported in conjunction with the use of ICD-10-CM diagnosis code Z32.01.
- This is usually done during the first 12 weeks before the ACOG antepartum note is started. Use CPT Category II code 0500F.
- Laboratory tests (excluding routine chemical urinalysis)
- Examples include CBC, liver functions, HIV testing, Blood glucose testing, sexually transmitted disease screening, and antibody screening for Rubella or Hepatitis, etc.
- Maternal or fetal echography procedures
- Obstetric ultrasound, NST, or fetal biophysical profile
- Depending on the insurance carrier, all subsequent ultrasounds after the first three are considered bundled
- Cerclage, or the insertion of a cervical dilator more than 24 hours from admission.
- External cephalic version (turning of the baby due to malposition)
- Amniocentesis (any method)
- Chorionic villus sampling (CVS)
- Fetal contraction stress test
- E/M services for management of conditions unrelated to the pregnancy during antepartum or postpartum care. The diagnosis should support these services.
- Examples include cardiac problems, neurological problems, diabetes, hypertension, hyperemesis, preterm labor, bronchitis, asthma, and urinary tract infection
- NOTE: These encounters could be office visits, clinic visits, emergency room, or inpatient admission/observation.
- Inpatient E/M services provided more than 24 hours before delivery
- Surgical Procedures during pregnancy
- Examples include urinary system, nervous system, cardiovascular, etc.
- Laceration repair of a third- or fourth-degree laceration at the time of delivery
- Per ACOG coding guidelines, this should be reported using modifier 22 of the CPT code used to bill.
- Contraceptive management services (insertions)
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List of CPT Codes
Maternity care and delivery CPT codes are categorized by the AMA. The following is a comprehensive list of all possible CPT codes for full term pregnant women.
IMPORTANT: Complications of pregnancy such as abortion (missed/incomplete) and termination of pregnancy are not included in this list.
The following codes can also be found in the 2021 CPT codebook.
Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
Global Package Code
Vaginal delivery only (with or without episiotomy and/or forceps);
Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care
Antepartum care only; 1-3 visits
Antepartum care only; 4-6 visits
Antepartum care only; 7 or more visits
Postpartum care only (separate procedure)
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
Global Package Code
Cesarean delivery only;
Cesarean delivery only; including postpartum care
Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery
Global Package Code
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps);
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery
Global Package Code
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care
Maternity Obstetrical Care Medical Billing for Twin Delivery/Multiple Gestation
Some pregnant patients who come to your practice may be carrying more than one fetus. In such cases, certain additional CPT codes must be used.
ACOG has provided the following coding guidelines for vaginal, cesarean section, or a combination of vaginal and cesarean section deliveries.
To ensure accurate maternity obstetrical care medical billing and timely reimbursements for work performed, make sure your practice reports the proper CPT codes.
Type of Service/Procedure
Type of Twin
CPT Codes Reported
Vaginal Delivery of Twins
C-Section Delivery of Twins
Twin A & Twin B
Repeat Cesarean Delivery
Delivery of Twins
VBAC Delivery of Twins
Vaginal & C-Section Delivery of Twins
VBAC + repeat Cesarean Delivery of Twins
If both twins are delivered via cesarean delivery, report code 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care). This is because only one cesarean delivery is performed in this case.
However, if the cesarean delivery is significantly more difficult, append modifier 22 to code 59510. When reporting modifier 22 with 59510, a copy of the operative report should be submitted to the insurance carrier with the claim.
Split Care Performed/Itemization Billing
Some 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:
- The patient has received part of her antenatal care somewhere else (e.g. from another group practice).
- The patient leaves her care with your group practice before the global OB care is complete.
- Patient receives care from a midwife but later requires MD-level care.
- The patient has a change of insurer during her pregnancy.
In these situations, your practice should contact the insurance carrier and notify them of these changes. This will allow reimbursement for services rendered.
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:
- Antepartum care only. The following CPT codes apply based on how many visits a patient had with your practice:
- 59425: Antepartum care only, 4-6 visits
- 59426: Antepartum care only, 7 or more visits; E/M visit if only providing 1-3 visits
- Delivery only: CPT codes 59409, 59514, 59612, and 59620
- Postpartum care only: CPT code 59430
Maternity Obstetrical Care Medical Billing for High-Risk Pregnancies
In the case of a high-risk pregnancy, the mother and/or baby may be at increased risk of health problems before, during, or after delivery. In this case, special monitoring or care throughout pregnancy is needed, which may require more than 13 prenatal visits.
Examples of high-risk pregnancy may include:
- Advanced maternal age: pregnancy risks rise for mothers past the age of 35.
- Maternal health problems: pre-gestation medical complication such as hypertension, diabetes, epilepsy, thyroid disease, heart or blood disorders, poorly controlled asthma, and infections can increase pregnancy risk.
- Pregnancy-Related Complications: examples include gestation, diabetes and/or hypertension, poor fetal growth, premature rupture of membrane, abnormal placenta position, etc.
All these conditions require a higher and closer degree of patient care than a patient with an uncomplicated pregnancy.
As such, visits for a high-risk pregnancy are not considered routine. They should be reported in addition to the global OB CPT codes of 59400, 59510, 59610 or 59618.
If medical necessity is met, the provider may report additional E/M codes, along with modifier 25, to indicate that care provided is significant and separate from routine antepartum care. The claim should be submitted with an appropriate high-risk or complicated diagnosis code.
Examples of applicable ICD-10-CM codes:
Supervision of other high-risk pregnancies
Pre-existing hypertensive heart disease complicating pregnancy
Pre-existing hypertension with pre-eclampsia
Gestational [pregnancy-induced] edema and proteinuria without hypertension
Pre-existing type-1 diabetes mellitus, in pregnancy,
Liver and biliary tract disorders in pregnancy
Anemia in pregnancy
NOTE: When a patient who is considered high risk during her pregnancy has an uncomplicated delivery with no special monitoring or other activities, it should be coded as a normal delivery according to the usual codes.
Maternal-Fetal Medicine (MFM) Care
Maternal-fetal medicine specialists, also known as perinatologists, are physicians who subspecialize within the field of obstetrics. They focus on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.
Per ACOG, all services rendered by MFM are outside the global package. An MFM is allowed to bill for E/M services along with any procedures performed (such as ultrasounds, fetal doppler, etc.) with a modifier 25.
Make sure you double check all insurance guidelines to see how MFM services should be reported if the provider and MFM are within the same group practice.
When reporting ultrasound procedures, it is crucial to adhere closely to maternity obstetrical care medical billing and coding guidelines.
In particular, keep a written report from the provider and have images stored on file. As per AMA CPT and ultrasound documentation requirements, image retention is mandatory for all diagnostic and procedure guidance ultrasounds.
Appropriate image(s) demonstrating relevant anatomy/pathology for each procedure coded should be retained and available for review. CPT does not specify how the images are to be stored or how many images are required.
Modifiers may be applicable if there is more than one fetus and multiple distinct procedures performed at the same encounter. Incorrectly reporting the modifier will cause the claim line to be denied.
The following CPT codes cover ranges of different types of ultrasound recordings that might be performed. Make sure your practice is following correct guidelines for reporting each CPT code.
- 76801–76810: maternal and fetal evaluation (transabdominal approach, by trimester)
- 76811–76812: above and detailed fetal anatomical evaluation
- 76813–76814: fetal nuchal translucency measurement
- 76815: limited trans-abdominal ultrasound study
- 76816: follow-up trans-abdominal ultrasound study
- 76817: trans-vaginal ultrasound study
- 76818–76819: fetal biophysical profile
- 59025: fetal non-stress test
It is essential to read all the parenthetical guidelines that instruct the coder on how to properly bill the service for multiple gestations and more than one type of ultrasound.
Trimesters of Pregnancy
- 1st trimester: less than 14 weeks 0 days
- 2nd trimester: 14 weeks 0 days, to less than 28 weeks 0 days
- 3rd trimester: 28 weeks 0 days, to delivery
NOTE: For ICD-10-CM reporting purposes, an additional code from category Z3A.- (weeks of gestation) should ALWAYS be reported to identify specific week of pregnancy. (e.g., 15-week gestation is reported by Z3A.15).
Diagnosis Codes for Deliveries and Related Services
- Reporting Routine Prenatal Visits: routine prenatal visits are reported with a code from category Z34.- It should always be the first-listed diagnosis code unless the patient has other medical conditions affecting the pregnancy. Note that Z34.- codes should never be reported with an O code.
- Outcome of Delivery: should be included when a delivery has occurred (ICD-10-CM Z37.-).
- Normal Delivery (ICD-10-CM O80): only for full-term normal delivery and delivers a single, healthy infant. Additionally, there are no complications in the antepartum period, during the delivery, or in the postpartum period during the delivery encounter.
- If O80 is not appropriate, the primary diagnosis should reflect the main circumstances or complications of the delivery.
- If the patient is admitted with condition resulting in cesarean, then that is the primary diagnosis.
- If admitted for other reason, the admitting diagnosis is primary for admission and reason for cesarean linked to delivery.
- If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis.
- O Codes: An O code from ICD-10-CM Chapter 15 – “Pregnancy, Childbirth & the Puerperium” should always be reported for the delivery when the patient has experienced any current complication in the antepartum period, during the delivery, or in the postpartum period.
- All conditions treated or monitored can be reported (e.g., gestation diabetes, pre-eclampsia, prior C-section, anemia, GBS, etc.)
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):
- Obstetrician, Maternal Fetal Specialist, Fellow
- Certified Nurse Midwife (CNM)
- Nurse Practitioner Midwife (NPM)
- Certified Professional Midwife (CPM)
Depending 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).
Here at Neolytix, we are more than happy to assist your practice with billing, coding, EMR templates, and much more.
Reach out to us anytime for a free consultation.
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