Obstetrical/Maternity Service Guidelines
Billing and Reimbursement
Policy Number: RP-PI-003
Last Updated: July 19, 2023
Professional Obstetrical Guidelines include:
- Definitions
- Diagnosis Codes
- Obstetrical Complications:
- External cephalic version
- In-hospital treatment of complications
- Multiple deliveries
- Procedure codes global vs. non-global services
- Partial OB care
- Total OB care
Global vs. Non-Global Service:
Global maternity services include antepartum care, delivery and postpartum care. The total global service is submitted after delivery with the delivery date as the date of service. Non-global maternity services are payable as separate services outside of the total global service.
Initial OB Visit
Consistent with American Congress of Obstetricians and Gynecologists (ACOG) recommendations, Blue Cross and Blue Shield of Nebraska (BCBSNE) considers the “initial OB visit” the visit when the OB (prenatal/antepartum) record is begun and therefore part of “global OB care.”
Obstetrical Complications
For complex obstetrical patients with frequent antepartum visits or a complicated delivery, bill the appropriate procedure code with a Modifier -22 and include medical rationale (e.g., repair to a third- or fourth-degree perineal tear that occurs during delivery). Your claim will be reviewed to determine if extra reimbursement is warranted.
Services such as hemorrhage, hypertension, pre-eclampsia, infections, diabetes, etc., are not considered part of the global maternity services. Those services must be billed using the appropriate E/M code(s) and not the antepartum visit code.
Standby Services (CPT 99360)
Standby services during a C-section are not payable unless the standby physician performs some service or procedure during the delivery.
Bill the specific services or procedures performed rather than using the standby code. Standby services (CPT 99360) are a contract exclusion for BCBSNE and will be denied as member liability. If services are being rendered in a facility that requires “standby” (for example “at time of delivery”), the member should be advised by the facility and/or the physician that this charge will be their liability.
NICU Level of Care
See the NICU inpatient Level of Care policy.
External Cephalic Version
Reimbursement for total obstetric care does not include medically necessary external cephalic versions when performed after the 34th week of pregnancy. Reimbursement is limited to no more than two external cephalic version procedures during any one pregnancy.
In-Hospital Treatment of Complications
When hospitalization is required for severe complications during either the antepartum or postpartum period, in-hospital medical care fees may be made for the management of the condition. Payment will be subject to medical necessity review of medical records which support the additional care and direct attendance.
Multiple Deliveries
| Delivery Method | Twin A | Twin B | |
| Both twins delivered vaginally | Bill 59400 or 59610 | Bill 59409 or 59612 Modifier -59 | |
| Both twins delivered by caesarian | Bill 59510 or 59618 | Bill 59514 or 59620 Modifier -59 | Provide operative report and/or documentation for special consideration and additional reimbursement |
| One delivered vaginally and one by caesarian | 59400 | 59514 Modifier -59 |
Partial OB Care
In those instances when it is inappropriate to bill global OB care (i.e., transfer of care, coverage termination mid-term of the pregnancy, spontaneous abortion situations), the antepartum care should be billed at the time of service and within the timely filing period using the applicable CPT code as follows:
| Visits | Description |
| 1-3 | Bill the appropriate E/M code for each visit separately |
| 4-6 | Bill 59425 on one line |
| 7 or more | Bill 59426 on one line |
When billing 59425 or 59426, list the date the patient was seen for antepartum care. Example: If the antepartum visit was on May 15, you would put May 15 in both the FROM and TO DATES in Box 24A of the CMS 1500 claim form.
Box 24 G should always have a unit value of “1.” Include the date of delivery, if known, in the comments section of the claim.
| Transfer Reason | How to Bill |
| Patient is transferred permanently from one practitioner to another (different tax ID numbers (TINs)) | The initial physician should bill for the prenatal care provided prior to the delivery using the partial OB billing guidelines. The claim must clearly indicate a transfer of the patient to another physician. On a paper claim, note the transfer below the last item charge. For electronic filers, note the transfer in the available narrative field. Please indicate the name of the physician who will be assuming care for the patient. |
| Patient’s transfer of care is between practitioners under the same TIN | Regardless of location or specialty, we will accept only one claim for the total OB care. It is not permitted for an OB provider to bill total OB care when a provider under another TIN provides partial OB services to the patient. If a physician under a different TIN than the primary OB renders services (e.g., delivery only), that provider must separately bill their services according to partial OB billing guidelines. |
| OB provider changes TINs | If a practitioner changes TIN (e.g., transfers to another clinic) and continues to see a patient who was seen under the previous TIN, transfer of care guidelines applies. |
| Member changes insurance carriers during the pregnancy | Depending on services rendered, the provider may bill partial OB care or global. |
Postoperative Pain Control
Continuous infusion of anesthetic agents to operative wound sites using an elastomeric pump is scientifically validated as a technique for postoperative pain control for surgeries typically requiring oral or parenteral narcotics for pain relief.
Trade names of elastomeric pump and associate catheters that have received approval for marketing from the U.S. Food and Drug Administration (FDA), include, but are not limited to, Infusor SystemTM, On-Q® Post Op Pain Relief System, On-Q SoakerTM catheter delivery system and the Pain BusterTM Pain Management System. While the charge for the elastomeric pump may be covered, the insertion will be denied as global to the surgery.
Institutional
Obstetrical Guidelines include:
- Mothers and newborns
- Obstetrical complications
Mothers and Newborns
Submit separate claims for a mother and her newborn.
Obstetrical Complications
Standby services during a C-section are not payable unless the standby physician performs some service or procedure during the delivery. The specific services or procedures performed should be billed rather than using the standby code of 99360.
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