Code Code Description
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
In this global service, the provider and nonphysician healthcare providers in the practice provide all of the antepartum care, admission to the hospital for delivery, labor management, including induction of labor, fetal monitoring, use of low forceps and episiotomy, vaginal delivery of the fetus and placenta, and inpatient and outpatient postpartum care. Typical global services begin at eight to ten weeks gestation, with a full term vaginal delivery at thirty–nine to forty weeks gestation, and routine outpatient postpartum care forsix weeks following delivery.
59409 – Vaginal delivery only (with or without episiotomy and/or forceps)
In this procedure, the provider provides admission to the hospital for delivery, labor management, including induction of labor, fetal monitoring, use of low forceps, and episiotomy, vaginal delivery of the fetus and placenta on the same date of service.
59410 – Vaginal delivery only (with or without episiotomy and/or forceps)
In this global service, the provider admits the patient to the hospital for delivery, labor management, including induction of labor, fetal monitoring, use of low forceps, and episiotomy, vaginal delivery of the fetus and placenta, and inpatient and outpatient postpartum care. Typical postpartum care ends after one or more outpatient visits up to six weeks following delivery.
Global obstetrical (OB) care (CPT code 59400) includes:
• Routine prenatal care in any trimester
• Delivery
• Postpartum care
If you provide all of the client’s prenatal care, perform the delivery, and provide the postpartum care, you must bill using the global OB procedure code.
Note: Bill the global obstetric procedure code if you performed all of the services and no other provider is billing for prenatal care, the delivery, or postpartum care. (See WAC 182- 533-0400(5). If you provide all or part of the prenatal care and/or postpartum care but you do not perform the delivery, you must bill the agency for only those services provided using the appropriate prenatal and/or postpartum codes. In addition, if the client obtains other medical coverage or is transferred to an agency-contracted managed care organization (MCO) during pregnancy, you must bill for only those services provided while the client is enrolled with agency fee-for-service.
CPTCode Short Description EPA Number
CPT: 59400, 59409, 59410 Elective delivery or natural delivery at or over 39 weeks gestation 870001378
CPT: 59400, 59409, 59410 Natural delivery before 39 weeks 870001375
Application
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.
Policy 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.
Reimbursement Guidelines
Global Obstetrical 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, 59510, 59610 and 59618 UnitedHealthcare 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.
UnitedHealthcare will adjudicate claims submitted with either a single date of service or a date span when submitting global OB codes. To facilitate claims processing, report one unit, whether submitted with a date span or a single date of service.
Please refer to the Itemization of Obstetrical Services section of this policy for guidance on coding services when a patient changes insurers or group practices during her pregnancy.
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
• Administration/induction of intravenous oxytocin
• Insertion of cervical dilator on same date as delivery
• 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
• Educational services e.g. breastfeeding, lactation, and basic newborn care
UnitedHealthcare will not separately reimburse the above services when reported separately from the global OB code. 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 UnitedHealthcare’s “Increased Procedural Services Policy.”
B. 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.
• 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 Ultrasound Procedure section.
• Amniocentesis, any method
• Amnioinfusion
• Chorionic villus sampling (CVS)
• Fetal contraction stress test
• Fetal non-stress test
• External cephalic version
• Insertion of cervical dilator 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 the 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)
C. 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.
UnitedHealthcare 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.
Refer to the High Risk/Complication Diagnosis Code List in the Attachment Section Maternal-Fetal Medicine Specialists
A patient may see a Maternal-Fetal Medicine (MFM) Specialist in addition to a regular OB/GYN physician. According to ACOG, the MFM services fall outside the routine global OB package. Therefore, the reporting of these services is dependent on whether the MFM specialists are part of the same group practice as the OB/GYN physician. If the MFM has the same federal tax identification number as the OB/GYN physician, the specialist should report the E/M services with modifier 25 to indicate significant and separately identifiable E/M services; use of modifier 25 will indicate that the MFM service is not part of the routine antepartum care supplied by that physician group. However, if the MFM is in a different group practice than the physician(s) and other health care professionals supplying the routine antepartum care, modifier 25 is not necessary.
D. E/M Service with an Obstetrical Ultrasound Procedure
UnitedHealthcare follows ACOG coding guidelines and considers an E/M service on the same date of service, by the Same Individual Physician or Other Health Care Professional to be separately reimbursed in addition to an OB ultrasound procedures (CPT codes 76801-76817 and 76820-76828) only if the E/M service is a separate and distinct service and is submitted with the appropriate modifier.
Note: The UnitedHealthcare Professional Technical Component Policy considers the review and interpretation (modifier 26) of a radiology service, e.g., OB ultrasound, to be included in the E/M service when performed by the Same Individual Physician or Other Health Care Professional on the same date of service for the same patient. These services with a 26 modifier are not distinct from the E/M service when both are provided on the same day. Modifier 25 appended to the E/M code has no impact as to whether the interpretation of the OB ultrasound is considered a separately reimbursable service.
For more information on the requirements for reimbursement of the interpretation of an OB ultrasound when reported on the same date of service as an E/M code refer to UnitedHealthcare’s “Professional/Technical Component Policy” section titled “Professional Component with an Evaluation and Management Services.”
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. For additional information, refer to the Questions and Answers section, Q&A #5
Itemization of Obstetrical Services
Global OB codes are utilized when the Same Group Physician and/or Other Health Care Professional provides all components of the OB package. However, physicians from different group practices may provide individual components of maternity care to a patient throughout a pregnancy. Although Obstetric (OB) Related E/M Services should be billed as a global package, itemization of Obstetric (OB) Related E/M Services may occur in the following situations:
• A patient transfers into or out of a physician or group practice
• A patient is referred to another physician during her pregnancy
• A patient has the delivery performed by another physician or other health care professional not associated with her physician or group practice
• A patient terminates or miscarries her pregnancy
• A patient changes insurers during her pregnancy
A. Antepartum Care Only
The CPT Editorial Board created codes 59425 (Antepartum care only; 4-6 visits) and 59426 (Antepartum care only; 7 or more visits) to accommodate for situations such as termination of a pregnancy, relocation of a patient or change to another physician. In these situations, all the routine antepartum care (usually 13 visits) or global OB care may not be provided by the Same Group Physician and/or Other Health Care Professional. The antepartum care only CPT codes 59425 or 59426 should be reported by the Same Group Physician and/or Other Health Care Professional when:
• The antepartum care provided does not meet the routine antepartum care definition of the global OB package as defined by CPT; or
• The antepartum care provided is less than the typical number of visits (usually 13) during the global OB package as defined by ACOG.
If the patient is treated for antepartum services only, the physician and/or other health care professional should use CPT code 59426 if 7 or more visits are provided, CPT code 59425 if 4-6 visits are provided, or itemize each E/M visit if only providing 1-3 visits.
As described by ACOG and the AMA, the antepartum care only codes 59425 and 59426 should be reported as described below:
• A single claim submission of CPT code 59425 or 59426 for the antepartum care only, excluding the confirmatory visit that may be reported and separately reimbursed when the antepartum record has not been initiated.
• The units reported should be one.
• The dates reported should be the range of time covered. For example, if the patient had a total of 4-6 antepartum visits then the physician and/or other health care professional should report CPT code 59425 with the “from and to” dates for which the services occurred.
In the event that all the antepartum care was provided, but only a portion of the antepartum care was covered under UnitedHealthcare, then adjust the number of visits reported and the “from and to” dates to reflect when the patient became eligible under UnitedHealthcare coverage.
B. Delivery Services Only
Per the CPT book, “Delivery services include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery.”
The following are the CPT defined delivery only codes: 59409, 59514, 59612, and 59620
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.
If the same individual or Same Group Physician and/or Other Health Care Professional provided the delivery component in addition to postpartum care services, please refer to the Delivery Only including Postpartum Care section of this policy.
For deliveries involving twin or triplet gestations, see the Multiple Gestation section of this policy. 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
• Delivery of the placenta; any method
• Repair of first or second-degree lacerations
UnitedHealthcare will not separately reimburse for these services when one of the delivery-only codes is reported. UnitedHealthcare considers insertion of cervical dilator 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. Claims submitted with modifier 22 must include medical record documentation which supports the use of the modifier; please refer to the Increased Procedural Services section of this policy and UnitedHealthcare’s “Increased Procedural Services Policy.”
OB Global Codes
• 59400: Vaginal delivery
• 59510: Primar C/S 59510: Primary C/S
• 59610: VBAC
• 59618: Failed VBAC, Repeat C/S
Breakdown of OB Global
• Break down of code 59400
– Antepartum 41% Antepartum 41%
– Intrapartum 36%
• This includes H&P and labor management
– Vaginal delivery 15%
– Postpartum 8% Postpartum 8%
• This includes inpatient and outpatient visits.
Billing More Than the Global
• Twins
Vaginal Delivery Baby A 59400
Baby B 59409-59
Maternity Global Period
The 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.
• For claims processed on or after July 1, 2018 (regardless of service date):
o The global maternity period for vaginal delivery is 49 days (59400, 59410, 59610, & 59614).
o The global maternity period for cesarean delivery is 90 days (59510, 59515, 59618, & 59622). A cesarean delivery is considered a major surgical procedure.
• For claims processed prior to July 1, 2018, Moda Health uses a Maternity Global Period of 45 days.
• The date of delivery is day zero. The day after delivery is postpartum day one, just as the surgery global period days are calculated. (RPM011A)
