With changing industry regulations, new codes and coding standards, and varying payer reimbursement rates and policies, all types of medical practices are facing increased workloads related to billing. For accurate obstetrics medical billing and coding, providers need to be up-to-date on CPT, ICD-10, and HCPCS code changes, revisions to modifiers and modifier use, payer policies, regulatory changes, documentation requirements, and much more. However, there are many factors that make the ob-gyn billing more complex than other specialties, leading many providers to rely on experienced physician billing companies to manage the process.
Billing Maternity Care Services
Maternity care includes antepartum care, delivery services, and postpartum care. The elements that impact billing for these services are as follows:
- Global period: The global period is the time during which any services provided are included in the payment for the service. The global period for obstetric services covers antepartum, delivery, and postpartum care. For gynecologic surgeries, the global period will differ based on the surgery. For billing purposes, the obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period (56 days after vaginal delivery and 90 days after c-section). Points to note (www.mdedge.com):
- Routine history and physical examination performed prior to a major surgery is usually included in global package and should not be billed separately
- Surgical clearance for a patient’s condition, such as hypertension, heart problems, etc, can be billed separately, but these are usually performed by someone other than the operating surgeon
- Generally, procedures performed in the hospital setting have a 10- or 90-day global period. Related E/M service(s) should not be billed separately during this period, and appropriate modifiers should be appended to report services.
- Global Obstetrical Care CPT codes: The global OB package CPT codes are:
- 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
- 59510 – Routine obstetric care including antepartum care, cesarean delivery and postpartum care
- 59610 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery
- 59618 – Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean deliveryThe global obstetric (OB) code should be billed whenever the Same Group Physician and/or Other Health Care Professionals of the group provide all components of the patient’s obstetrical care. Pregnancy related E/M visits should not be reported using individual E/M billing codes.
- Maternity care bundling: In bundling, one service is recognized as the primary service, and any additional services provided during the same session are included in the payment. The physician is paid only for the primary service. Knowing payer rules on bundling is crucial. While CMS publishes its list of primary procedures and associated secondary procedures on a quarterly basis, many payers have their own bundling rules.
According to CPT and ACOG guidelines, services bundled in the global OB package include:
- All routine prenatal visits until delivery (approximately 13 for uncomplicated cases)- Initial and subsequent history and physical exams
- Recording of weight, blood pressures and fetal heart tones
- Routine chemical urinalysis (CPT codes 81000 and 81002)
- Admission to the hospital including history and physical
- Inpatient E/M service provided within 24 hours of delivery
- Management of uncomplicated labor
- Vaginal or cesarean section delivery
- Delivery of placenta (CPT code 59414)
- Administration/induction of intravenous oxytocin (CPT codes 96365 – 96367)
- Insertion of cervical dilator on same date as delivery (CPT code 59200)
- Repair of first or second degree lacerations
- Simple removal of cerclage (not under anesthesia)
- Uncomplicated inpatient visits following delivery
- Routine outpatient E/M services provided within 6 weeks of delivery
- Postpartum care only (CPT code 59430)
- Educational services e.g. breastfeeding, lactation, and basic newborn care
Providers should not bill the above-listed services separately as they bundled as part of the routine OB care visits. These services are not reimbursed when reported separately from the global OB code. To ensure correct payment, providers need to work with their medical billing and coding company to identify all potential bundles before billing.
- Services unrelated to pregnancy: Patients may seek care for routine illnesses such as colds, flu, upper respiratory infections, headaches, muscle aches, heartburn, etc. If the provider rendering global maternity care renders services unrelated to pregnancy, these separately identifiable services should be documented and reported separately with the appropriate inpatient or outpatient E/M code, using the condition unrelated to pregnancy as the primary diagnosis code. It is important that the medical coding service provider is prepared to review, audit, and bill for such E/M services that are OB/maternity related, but are not part of routine care.
- Modifiers: The modifiers commonly appended when reporting ObGyn services are:
22, Increased procedural services
24, Unrelated E/M during the postoperative period (this modifier does not apply during the antepartum period for pregnancy)
25, Significant and separate E/M on the same date as another service or minor procedure
52, Reduced services
57, Decision to perform major surgery the day of or the day before the surgery
59, Distinct procedural service (used when 2 procedures are bundled and a modifier is allowed)
76, Repeat procedure or service by the same physician or other qualified health care professional
77, Repeat procedure or service by another physician or other qualified health care professional
79, Unrelated procedure during the postoperative period
Overcome OBGYN Medical Billing Challenges with Expert Support
Maximizing reimbursement involves good documentation, up-to-date CPT codes linked to specific and accurate medical indications and diagnosis codes, the use of appropriate modifiers, and knowledge of payer rules. Obstetrics medical billing services are the best option to ensure accurate reporting of services for appropriate reimbursement.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.