REIMBURSEMENT GUIDELINES
Global Obstetrical (OB) Care
As defined by the American Medical Association (AMA), “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” When the Same Group Physician and/or Other Health Care Professional provides all components of the OB package, report the global OB package code.
The Current Procedural Terminology (CPT®) book identifies the Global OB codes as:
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 delivery Oxford reimburses for these global OB codes when all of the antepartum, delivery and postpartum care is provided by the Same Group Physician and/or Other Health Care Professional.
Oxford will adjudicate claims submitted with either a single date of service or a date span when submitting global OB codes.
To facilitate claims processing, a single date of service may be utilized.
Duplicate Obstetrical Services
Duplicate OB services are defined as any of the below listed CPT codes provided by the same or different physician on the same or different date of service. This follows the coding guidelines defined by the AMA. CPT codes for Global OB Care fall into one of three categories:
* Single-component codes (for example, delivery only)
* Two-component codes (for example, delivery including postpartum care)
* Three-component, or complete, global codes (including antepartum care, delivery, and postpartum care) The codes are as follows: 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, and 59622.
The following are the CPT defined Delivery-Only codes:
* 59409 – Vaginal delivery only (with or without episiotomy and/or forceps)
* 59514 – Cesarean delivery only
* 59612 – Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)
* 59620 – Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery The Delivery Only codes should be reported by the Same Group Physician and/or Other Health Care Professional for a single gestation when:
* The total OB package is not provided to the patient by the same single physician or group practice and itemization of services needs to occur.
* Only the delivery component of the maternity care is provided and the postpartum care is performed by another physician or group of physicians.
Items Included in the Delivery Services
According to CPT and ACOG coding guidelines, the following services are included in the delivery services codes and should not be reported separately:
* Admission to the hospital
* The admission history and physical examination
* Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps, with or without vacuum extraction), or cesarean delivery, external and internal fetal monitoring provided by the attending physician
* Intravenous (IV) induction of labor via oxytocin (CPT codes 96365 – 96367)
* Delivery of the placenta; any method
* Repair of first or second degree lacerations
Oxford will not separately reimburse for these services when one of the delivery codes is reported.
Oxford considers insertion of cervical dilator (CPT 59200) to be included if performed on the same date of delivery. Per ACOG coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB (59400, 59610) or delivery only (59409, 59410, 59612 and 59614) codes.
OVERVIEW
Maternity care includes antepartum care, delivery services, and postpartum care. This policy describes reimbursement for global obstetrical (OB) codes and itemization of maternity care services. In addition, the policy indicates what services are and are not separately reimbursable to other maternity services.
Unless otherwise specified, for the purposes of this policy Same Group Physician and/or Other Health Care Professional includes all physicians and/or other health care professionals of the same group reporting the same federal tax identification number.
Oxford may allow a newly enrolled woman to continue maternity care on an in plan basis with a non-participating provider. This is referred to as Transitional Care. This will most likely result in a prorated claim.
Services Included in the Global Obstetrical Package
Per CPT guidelines and the American Congress of Obstetricians and Gynecologists (ACOG), the following services are included in the Global OB package (CPT codes 59400, 59510, 59610, 59618):
** 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 Evaluation and Management (E/M) service provided within 24 hours of delivery
** Management of uncomplicated labor
** Vaginal or cesarean section delivery (limited to single gestation; for further information, see Multiple Gestation section)
** 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)
Oxford will not separately reimburse the above services when reported separately from the global OB code.
Exceptions:
** Participating and non-participating New Jersey providers may elect to be reimbursed for maternity services rendered to a covered person enrolled with a New Jersey line of business on either a global (one payment for all services rendered during the term of the pregnancy for antepartum care, delivery and postpartum care) or on an installment basis (3 equal payments that when combined are the equivalent of the global payment for services rendered during the term of the pregnancy) for pregnancies that begin January 5, 2012 and after.
** If a non-participating provider in New York is eligible for a global payment and payment is requested before delivery, two dates of service prior to delivery may be reimbursed. Per ACOG coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614). Claims submitted with modifier 22 must include medical record documentation that supports the use of the modifier; please refer to the Increased Procedural Services section of this policy and Oxford’s Increased Procedural Services policy.
Services Excluded from the Global Obstetrical Package Per CPT guidelines and ACOG, the following services are excluded from the Global OB package (CPT codes 59400, 59510, 59610, 59618) and may be reported separately if warranted:
** Initial E/M to diagnose pregnancy if antepartum record is not initiated at this confirmatory visit. This confirmatory visit would be supported in conjunction with the use of ICD-10-CM diagnosis code Z32.01 (Encounter for pregnancy test, result positive).
** Laboratory tests (excluding routine chemical urinalysis)
** Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828). For additional information, see E/M Service with an Obstetrical (OB) Ultrasound Procedure section.
** Amniocentesis, any method (CPT codes 59000 or 59001)
** Amnioinfusion (CPT code 59070)
** Chorionic villus sampling (CVS) (CPT code 59015)
** Fetal contraction stress test (CPT code 59020)
** Fetal non-stress test (CPT code 59025)
** External cephalic version (CPT code 59412)
** Insertion of cervical dilator (CPT code 59200) more than 24 hours before delivery
** E/M services for management of conditions unrelated to the pregnancy (e.g., bronchitis, asthma, urinary tract infection) during antepartum or postpartum care; the diagnosis should support these services. For further information please refer to the Non-Obstetric Care section of this policy.
** Additional E/M visits for complications or high risk monitoring resulting in greater than the typical 13 antepartum visits; per ACOG these E/M services should not be reported until after the patient delivers. Append modifier 25 to identify these visits as separately identifiable from routine antepartum visits. For further information, please refer to High Risk/Complications section of this policy.
** Inpatient E/M services provided more than 24 hours before delivery
** Management of surgical problems arising during pregnancy (e.g., appendicitis, ruptured uterus, cholecystectomy). High Risk/Complications
A patient may be seen more than the typical 13 antepartum visits due to high risk or complications of pregnancy. These visits are not considered routine and can be reported in addition to the global OB CPT codes of 59400, 59510, 59610 or 59618. The submission of these high risk or complication services is to occur at the time of delivery, because it is not until then that appropriate assessment for the number of antepartum visits can be made. Per ACOG coding guidelines, if a patient sees an obstetrician for extra visits to monitor a potential problem and no problem actually develops, the physician is not to report the additional visits; only E/M visits related to a current complication can be reported separately. Oxford will separately reimburse for E/M services associated with high risk and/or complications when modifier 25 is appended to indicate it is significant and separate from the routine antepartum care and the claim is submitted with an appropriate high risk or complicated diagnosis code.
Evaluation and Management (E/M) Service with an Obstetrical Ultrasound Procedure
Oxford follows ACOG coding guidelines and considers an E/M service to be separately reimbursed in addition to an OB ultrasound procedures (CPT codes 76801-76817 and 76820-76828) only if the E/M service has modifier 25 appended to the E/M code.
If the patient is having an OB ultrasound and an E/M visit on the same date of service, by the Same Individual Physician or Other Health Care Professional, per ACOG coding guidelines the E/M service may be reported in addition to the OB ultrasound if the visit is identified as distinct and separate from the ultrasound procedure. Per CPT guidelines, modifier 25 should be appended to the E/M service to identify the service as separate and distinct.
Laboratory Tests
Oxford follows ACOG coding guidelines and considers CPT laboratory codes 81000 and 81002 as included in the global antepartum or global OB service when submitted with an OB diagnosis code in an office setting. Assistant Surgeon and Cesarean Sections Only a non-global cesarean section delivery code (CPT codes 59514 or 59620) is a reimbursable service when submitted with an appropriate assistant surgeon modifier. Refer to the Assistant Surgeon policy for additional information regarding modifiers and reimbursement.
Prolonged Physician Services
Prolonged physician services for labor and delivery services are not separately reimbursable services. CPT codes forprolonged physician services (99354, 99355, 99356, 99357, 99358, 99359, 99415 and 99416) are add-on codes used in conjunction with the appropriate level E/M code. As described in ACOG coding guidelines, prolonged services are not reported for services involving indefinite periods of time such as labor and delivery management.
QUESTIONS AND ANSWERS
1 Q: Will Oxford reimburse an attending physician for fetal monitoring during labor (CPT codes 59050 or 59051) ?
A: No, these codes are specifically for fetal monitoring during labor by a consulting physician.
2 Q: Why is insertion of cervical dilator (CPT code 59200) considered part of the delivery service and not reimbursed separately**
A: According to ACOG’s coding guidelines, CPT code 59200 (insertion of a cervical dilator, e.g., laminaria, prostaglandin) performed on the day of delivery is a component included in the delivery service. Therefore, Oxford considers this service included in the patient’s delivery service and does not consider it a separately reimbursable service unless performed and reported on a date of service other than the date of delivery.
3 Q: If one physician performs the delivery only, and a physician in another practice (different federal tax identification number) provides all of the postpartum care, how should these services be reported ?
A: The physician who performs the delivery only should report the delivery service without a postpartum component, e.g., CPT code 59409 (vaginal delivery only). The other physician should report the postpartum care only code (CPT code 59430).
4 Q: If one physician performs the delivery only (e.g., CPT code 59409), and a different physician in the same practice (same federal tax identification number) provides all of the postpartum care (i.e., CPT code 59430), how should these services be reported ?
A: Per the CPT book, the procedure code that most accurately reflects the services performed should be used. In this instance since these physicians are of the same physician group (same federal tax identification number), CPT code 59410 would be reported as the code description identifies both the delivery and postpartum care.
5 Q: How is an OB procedure reimbursed when reported by two different physicians with the same or different federal tax identification numbers reporting a component and a global OB care code during the same global obstetrical period ?
A: When Obstetrical services are eligible for reimbursement under this policy, only one provider will be reimbursed when multiple providers bill duplicate obstetrical services. Oxford follows a “first in, first out” claim payment methodology in determining which claim will be considered for reimbursement when claims for duplicate obstetrical services are received that involve component and global OB care services.
6 Q: Should a postpartum visit be provided within the ACOG standard six-week period ?
A: The postpartum period includes routine office or outpatient postpartum visit(s) usually, but not necessarily, performed 6 weeks following delivery. If a physician routinely performs more than one postpartum outpatient visit in an uncomplicated case, the extra visit(s) is not billed separately. When a postpartum visit is scheduled, but the patient does not keep the appointment, the physician’s documentation should reflect that the patient did not appear for the scheduled postpartum visit. This visit does not have to be refunded if a global OB code was previously submitted. If a patient returns to the office well after their scheduled postpartum visit (e.g., 6 months later) this visit may be reported separately since the global period would no longer apply.
7 Q: Are contraceptive management services included in postpartum care ?
A: Oxford will consider separate reimbursement for contraceptive management services when provided during the postpartum period only when submitted with CPT codes 11975 (insertion, implantable contraceptive capsules), 57170 (diaphragm or cervical cap fitting with instructions), or 58300 (insertion of intrauterine device, IUD).
8 Q: How should the initial OB visit be reported ?
A: Per ACOG guidelines, if the obstetrical record is not initiated, then the office place of service visit should be reported separately by using the appropriate E/M CPT code (99201-99215, 99241-99245 and 99341- 99350) and ICD-10-CM diagnosis code of Z32.01. If the obstetrical record is initiated during the confirmatory visit, then the confirmatory visit becomes part of the global obstetric package and is not reported separately.
9 Q: What does the phrase “changes insurers” mean in relation to itemization of Obstetric (OB) Related E/M services ?
A: For the purposes of this policy, “insurer” means a third party payer. If a patient changed insurers during her obstetrical care, the provider and/or other health care professional would separate and submit the OB services that were provided in an itemized format to each insurer. For example, when reporting the antepartum care services, the code selection depends on how many visits were performed while covered under each insurer. The physician and/or other health care professional should report CPT code 59426 when 7 or more visits are provided, CPT code 59425 when 4-6 visits are provided, or an E/M visit when only providing 1-3 visits.
For Vaginal Deliveries
Bill vaginal deliveries for multiples using the guidelines outlined below:
For the first infant (Baby A):
o Use the most accurate/complete procedure code that describes the antenatal care, delivery history, current delivery type, and any postnatal care provided for the current pregnancy.
o Bill only one (1) unit of service for Baby A.
For example:
For vaginal delivery codes, you may choose and combine: 59400 or 59410 with 59409.
For vaginal deliveries (after a previous cesarean delivery), use: 59610 or 59614 with 59612.
For an additional infant (Baby B):
o Use one (1) of the above listed “delivery only” codes: 59409 or 59612.
o Choose the code associated with the same delivery history and type that you used for Baby A.
o Include modifier ‘22’ in the first position for Baby B.
o Bill one (1) unit of service for the additional infant.