Florida OBGYN Billing Guidelines: Comprehensive Coding Overview

OBGYN billing and coding in Florida work differently from those in many other states. If you’re an OBGYN provider, practice manager, coder, or medical biller, you’ve probably noticed that Florida’s Medicaid rules, informed consent requirements, ultrasound limitations, and reimbursement policies can feel more detailed and sometimes more restrictive. These differences matter because Florida’s healthcare system serves a high volume of maternity, gynecology, and family-planning patients, which makes accurate billing and clean documentation essential.

This guideline provides a clear overview of Florida OBGYN billing and coding, covering both national CPT/ICD-10 standards and Florida-specific rules that affect claim approvals, denials, and reimbursement.

Core Medicaid OB Framework in Florida

Florida Medicaid governs obstetrical, reproductive, and family planning services under the Reproductive Services Coverage Policy. This policy establishes the scope of covered OB services, applicable limits, and required documentation standards that providers must follow for compliant billing and reimbursement.

Governing Policy for Obstetrical Services

The Reproductive Services Coverage Policy applies to all Medicaid-covered:

• Obstetrical services
• Reproductive health services
• Family planning services

It defines which services are covered, the conditions under which they are payable, and the documentation needed to support medical necessity.

Pregnancy-Related Coverage Requirements

For pregnancy-related care, the policy specifies coverage for:

• Prenatal visits, including mandated Healthy Start screening
• Delivery services
• Postpartum care

Coverage is subject to defined visit limits and timeframes. All services must be tied to medical necessity and supported by appropriate clinical documentation to qualify for reimbursement.

Prenatal Care Coding for Florida Medicaid

Florida Medicaid applies a distinct coding structure for prenatal care, using H-codes rather than traditional CPT antepartum codes. Correct use of these codes is essential for compliant billing and reimbursement.

Initial Prenatal Assessment and Healthy Start Screening

• H1001 is used for the initial prenatal assessment, which includes the mandatory Healthy Start screening.
• This service is generally billed once per pregnancy.
• The TG modifier is applied when the pregnancy is classified as high-risk, based on proper clinical documentation.

Ongoing Prenatal Visits

• H1000 is used for ongoing prenatal care visits.
• These visits are billed by date of service, not as a bundled package.

Visit Limits and High-Risk Exceptions

• Routine pregnancies are typically limited to approximately 9–10 covered prenatal visits.
• Additional visits may be covered when the pregnancy is high-risk, and the medical record clearly supports the need for extended care.

Delivery and Postpartum Coding for Florida Medicaid

Florida Medicaid follows standard CPT maternity delivery coding while applying specific coverage limits for postpartum care. Correct code selection and adherence to visit limits are essential for compliant reimbursement.

Delivery Coding

Delivery services are billed using standard CPT maternity delivery codes, in accordance with AMA CPT guidelines and the Florida Medicaid fee schedule. Common examples include:

• 59409 – Vaginal delivery only
• 59514 – Cesarean delivery only
• Related VBAC and delivery-plus-postpartum CPT codes, when applicable

Providers must ensure the selected code accurately reflects the service rendered and aligns with Medicaid payment rules.

Postpartum Care Coding

Postpartum services are covered for up to two visits within 90 days after delivery. These services may be billed using:

• OB postpartum CPT code 59430, or
• An appropriate Evaluation and Management (E/M) code, when consistent with policy

Claims must reflect the correct service type and timing to qualify for reimbursement.

Global vs. Unbundled OB Billing in Florida

Obstetric billing in Florida differs significantly between commercial payers and Florida Medicaid, making it essential for practices to understand how each program defines and reimburses maternity care.

Global OB Billing Under Commercial Plans

Many commercial insurance plans, such as Florida Blue, continue to use a global maternity fee. This approach bundles:

• Routine prenatal care
• Delivery services
• Standard postpartum care

Global billing is commonly applied for fully insured and ACA plans, allowing maternity services to be reimbursed under a single global package when care is uninterrupted.

Florida Medicaid’s Unbundled OB Model

Florida Medicaid uses an unbundled maternity billing structure. Under this model:

• Prenatal care is billed using H-codes
• Delivery services are billed with separate CPT maternity delivery codes
• Postpartum visits are billed as distinct services

Practices must track and bill each component individually. Submitting a single global maternity code does not align with Florida Medicaid’s operational model and will result in billing issues.

Practical OBGYN Billing Tips for Florida

Accurate OB/GYN billing in Florida requires layering state policy, Medicaid fee schedules, and managed care plan rules to ensure compliant and complete reimbursement.

Layer Policy, Fee Schedules, and Plan Manuals

Providers should always combine the Reproductive Services Coverage Policy with:

• Current Florida Medicaid fee schedules
• Managed care plan maternity manuals (e.g., UHC, Sunshine Health, Clear Health Alliance)

This approach captures plan-specific nuances, such as:

• Multiple-birth billing
• Long-acting reversible contraception (LARC) coverage
• Modifier requirements for high-risk pregnancies

Build EHR Templates for Compliance

Effective electronic health record (EHR) templates should:

• Trigger H1001/H1000 with proper modifiers and risk flags
• Link deliveries to correct CPT codes and associated diagnoses
• Flag the 90-day postpartum window to ensure all covered visits are captured and billed within policy limits

Key Code Groups for Florida OBGYN Billing

Florida OB/GYN billing relies on three primary code sets:

1. Medicaid-specific prenatal HCPCS codes (H1000/H1001)
2. Standard CPT maternity delivery and postpartum codes
3. General OB/GYN E/M and procedure codes

Proper integration of these codes into practice workflows is essential for accurate billing, reduced denials, and compliance with both Medicaid and commercial payer requirements.

Florida Medicaid Prenatal H‑Codes

Florida Medicaid uses H-codes to bill for prenatal care. Correct code selection ensures claims are processed accurately and aligns with visit limits and risk-level requirements.

H1001 – Initial Prenatal Assessment

• Covers the first prenatal assessment
   
• Includes Healthy Start risk screening
   
• Billed once per pregnancy
   
• TG modifier is often applied for high-risk pregnancies
   

H1000 – Follow-Up Prenatal Visit

• Used for ongoing prenatal visits
   
• Billed per date of service
   
• Subject to Medicaid visit limits:
   
  • Routine pregnancies: standard number of visits
     
  • High-risk pregnancies: additional visits allowed with proper documentation
     

H1004 – At-Risk Enhanced Prenatal Care

• Applies to select home-visit scenarios for at-risk pregnancies
   
• Covers follow-up home visits
   
• Subject to visit limits as defined by Florida Medicaid
   

Using these H-codes accurately is critical for compliant prenatal billing and helps ensure full reimbursement under Florida Medicaid policy.

Core CPT Maternity Codes for All Payers

Accurate CPT coding is essential for OB/GYN billing across Medicaid and commercial payers. Maternity services are billed using specific CPT codes for antepartum care, delivery, and postpartum services.

Antepartum Only

• 59425 – Antepartum care for 4–6 visits
• 59426 – Antepartum care for 7 or more visits

Vaginal Delivery

• 59409 – Delivery only
• 59410 – Delivery including postpartum
• 59400 – Global routine OB package including antepartum, vaginal delivery, and postpartum

Cesarean Delivery

• 59514 – C-section only
• 59515 – C-section including postpartum
• 59510 – Global C-section package including antepartum and postpartum

VBAC / Delivery After Prior C-Section

• 59612 – Vaginal delivery only
• 59614 – Vaginal delivery including postpartum
• 59620 – C-section only after attempted VBAC
• 59622 – C-section including postpartum after attempted VBAC
• 59610 / 59618 – Global packages for VBAC deliveries

Proper selection of these CPT codes ensures claims reflect the exact service provided, supports accurate reimbursement, and aligns with payer-specific maternity billing rules.

Postpartum and Related OB Codes

Postpartum care is a critical component of maternity services, with specific billing rules under Florida Medicaid and other payers.

Postpartum-Only CPT Code

• 59430 – Postpartum care only, used when not included in a delivery package
• Billed separately from antepartum and delivery services

Florida Medicaid Postpartum Visit Limits

• Up to two postpartum visits are covered within 90 days after delivery
• Some MMA plans allow additional visits when delivery-only codes are billed, subject to plan-specific structure and documentation requirements

Accurate use of postpartum CPT codes ensures proper reimbursement and compliance with Florida Medicaid visit limits and managed care plan policies.

Common OBGYN E/M and Preventive Codes

In addition to maternity-specific codes, OB/GYN practices use general Evaluation & Management (E/M) and preventive codes to cover non-obstetric care or age-appropriate preventive services.

Office / Outpatient E/M Codes

• 99202–99205 – New patient visits for non-OB problems or pregnancy verification
• 99212–99215 – Established patient visits for non-OB issues
  These codes are billed separately from prenatal, delivery, or postpartum care.

Preventive / Annual GYN Codes

• 99384–99387 – Preventive visits for new patients, by age
• 99394–99397 – Preventive visits for established patients, by age
  These are typically used outside the pregnancy episode and follow age- and status-specific guidelines.

High-Value Florida-Specific References

• Florida Medicaid Reproductive Services Coverage Policy – Defines coverage, visit counts, and documentation requirements for prenatal, delivery, and postpartum care.
• Plan-specific maternity guides – Published by managed care plans (e.g., Humana, UHC, Clear Health Alliance) to clarify:
  • H1000/H1001 usage
  • Visit limits
  • Delivery and postpartum billing rules

A payer grid can be developed next to compare which of these codes are accepted as global vs unbundled across Florida Medicaid, top MMA plans, and Florida Blue, helping practices streamline billing workflows.

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Our dedicated BillingFreedom specialists work round-the-clock to verify modifiers, link CPT codes to correct ICD-10 diagnoses, and reconcile high-volume postpartum visits. By leveraging advanced billing protocols and Florida Medicaid rules, we help practices reduce denials by up to 35% and increase net revenue by 20–25%. Partner with BillingFreedom today for stress-free billing, improved cash flow, and seamless OBGYN billing services in Florida tailored for maximum efficiency and compliance.

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