Nevada Medicaid OB Billing Requirements: Eligibility, Coverage & Documentation Standards

Obstetrical (OB) services under Nevada Medicaid follow both federal and state regulations that dictate how prenatal care, deliveries, and postpartum services are billed and coded. Proper billing practices are essential to ensure compliance, accurate reimbursement, and reduced claim denials resulting from coding or procedural errors. 

This guide provides a clear overview of Nevada Medicaid OB billing requirements, including eligibility, coverage rules, documentation standards, and best practices for submitting claims under the state’s Medicaid program.

Nevada Medicaid OB Billing: Eligibility, Coverage & Documentation

This guide provides an overview of eligibility, billing, coding, and documentation requirements for OB services under Nevada Medicaid.

Eligibility and Coverage Periods

Nevada Medicaid provides comprehensive coverage for pregnant women. 

• A woman eligible in any month of pregnancy remains eligible throughout pregnancy and up to 60 days postpartum. This ensures that all prenatal, delivery, and postpartum services are consistently covered, reducing gaps that could result in denied claims.
• Newborns born to Medicaid-eligible mothers may remain eligible up to one year if residing with the mother. Continuous eligibility for both mother and child is critical for seamless billing and to prevent coverage interruptions during the postpartum period.

Global OB Billing vs. Component Billing

Using the correct billing method, global or component, ensures compliance and reduces claim denials.

Nevada Medicaid encourages global obstetrical billing when prenatal care, delivery, and postpartum care are all provided by the same provider or practice. This simplifies claims and ensures a single payment covers the entire maternity episode.

Global OB CPT Codes

• 59400 – Routine vaginal delivery (global)
• 59510 – Routine cesarean delivery (global)
• 59610 / 59618 – VBAC global codes (vaginal birth after cesarean)

Eligibility for Global Payment: The provider must have:

1. Provided at least 7 prenatal visits
2. Performed the delivery
3. Provided postpartum care

If any of these criteria are not met, for instance, if care is split among multiple providers, services must be billed using component codes:

• Antepartum visits only: 59425 (4–6 visits), 59426 (7+ visits)
• Delivery only: 59409 (vaginal), 59514 (cesarean)
• Postpartum only: 59430

Component billing requires clear documentation for each segment to support accurate payment and reduce denials.

Coding & Diagnosis Guidelines

Accurate CPT and ICD-10 coding supports medical necessity and ensures claims are approved without delays in Nevada. These are the must-do list:

• All OB claims must use the appropriate CPT procedural codes and ICD-10 Chapter 15 diagnosis codes. 
• Correct coding reflects the services provided, supports medical necessity, and ensures claims are accepted without unnecessary audits. 
• Proper diagnosis coding also provides clinical context, helping payers understand the patient’s course of care and reducing the risk of denials.

Prior Authorization and Provider Enrollment

Confirming PA requirements in Nevada and provider enrollment before service prevents claim rejections.

Prior Authorization (PA): Certain ancillary OB services, like repeated ultrasounds or specialized testing, require PA through the Nevada Medicaid portal. Verifying PA requirements before billing prevents rejected claims and ensures compliance with Medicaid rules.

Provider Enrollment: Providers must be enrolled with Nevada Medicaid at the time of service. Services rendered by unenrolled providers are not reimbursable, which is a common reason for claim denials or recoupments.

Presumptive Eligibility for Pregnancy (PPE)

PPE allows immediate access to prenatal care while full Medicaid eligibility is being processed.

Nevada Medicaid allows Pregnancy Presumptive Eligibility, enabling qualified entities to determine preliminary Medicaid coverage so prenatal care can begin immediately. PPE ensures early access to care and helps prevent gaps in coverage that could delay treatment or complicate billing. While coverage is temporary and limited, it remains an important tool for the timely initiation of maternity care.

Documentation Requirements

To support OB Medicaid claims, ensure documentation includes:

• Prenatal visit dates and content
• Delivery summaries and delivery type
• Postpartum care notes
• Supporting documentation for any additional services (e.g., ultrasounds, ancillary procedures)

Comprehensive documentation is essential for compliance and audit readiness.

Common Denials and How to Avoid Them

Common causes of OB Medicaid claim denials include:

• Incorrect use of global vs component codes
• Billing when eligibility has lapsed
• Missing provider enrollment
• Lack of prior authorization when required

CPT Guidelines for Nevada Medicaid OB Billing

This section explains how to use CPT codes for delivery, antepartum, and postpartum services under Nevada Medicaid, including global and component billing scenarios.

Delivery CPT Codes

Delivery only (no antepartum or postpartum care provided)

59409 – Vaginal delivery

59514 – Cesarean delivery

59612 – Vaginal delivery after previous cesarean (VBAC)

59620 – Cesarean delivery following attempt of vaginal delivery after previous VBAC

Delivery with postpartum care (no antepartum care provided)

59410 – Vaginal delivery with postpartum care

59515 – Cesarean delivery with postpartum care

59614 – VBAC vaginal delivery with postpartum care

59622 – VBAC cesarean delivery with postpartum care

Delivery with less than 7 prenatal visits (no postpartum care)

Routine prenatal visits should be billed using appropriate E/M or antepartum CPT codes, following the Antepartum Care Schedule. Delivery-only codes should be billed separately.

Delivery with less than 7 prenatal visits, and postnatal care

Routine prenatal visits should be billed using appropriate E/M or Antepartum CPT codes, following the Antepartum Care Schedule. Delivery with postpartum care should be billed separately.

Global OB services (7+ prenatal visits, delivery, and postpartum care)

59400 – Vaginal delivery with routine antepartum and postpartum care

59510 – Cesarean with routine antepartum and postpartum care

59610 – VBAC vaginal delivery with routine antepartum and postpartum care

59618 – Cesarean delivery following attempt of vaginal delivery after previous VBAC, with routine antepartum and postpartum care

Transfer of Care

If a provider provides all or part of the antepartum and/or postpartum care but does not perform delivery due to termination of the pregnancy or referral to another provider, reimbursement is based upon the antepartum and postpartum care CPT codes.

Antepartum and Postpartum CPT Codes

• 1–3 routine visits: Bill individual visits using appropriate E/M CPT codes, following the antepartum visit schedule.
• 4–6 routine visits: 59425 – Antepartum care only, 4–6 visits
• 7 or more routine visits: 59426 – Antepartum care only, 7 or more visits
• Postpartum care only: 59430 – Postpartum care only

Antepartum Care Schedule

Routine prenatal visits include:

• Initial visit
• Monthly visits up to 28 weeks gestation
• Bi-weekly visits to 36 weeks gestation
• Weekly visits until delivery

Up to 13 antepartum visits are covered for routine examinations, including weight, blood pressure, fetal heart tones, and routine urinalysis.

Non-Routine Maternity Care / Complications of Pregnancy

Visits outside of the Antepartum Care Schedule for complications or non-routine care should be billed using the appropriate E/M CPT codes. Use modifier 25 to indicate a separately identifiable service.

Note: Non-routine visits within the global surgical period may deny when billed with a normal pregnancy diagnosis or gestational age diagnosis (233.1, 234.00, 234.80, 234.90, or Z3A.0–Z3A.49). Diagnosis codes must be pointed correctly on the claim line.

BillingFreedom Expert Nevada Medicaid OB Billing Support

At BillingFreedom, we specialize in Nevada Medicaid OB billing, helping practices navigate the complexities of eligibility, coverage, coding, and documentation requirements. Whether it’s global OB packages or component billing, our team ensures your claims are accurate, compliant, and designed to minimize denials.

We track prenatal visits, delivery dates, and postpartum care, verify provider enrollment, and follow prior-authorization rules to ensure your practice receives timely reimbursement. Our experts also provide guidance on ICD-10 and CPT coding, proper documentation, and best practices for audit readiness.

Partnering with BillingFreedom means you can focus on providing high-quality care while we handle the intricacies of Nevada Medicaid OB billing, helping your practice stay compliant, reduce denials, and maximize revenue.

To prevent denials, providers should perform regular eligibility checks and conduct billing audits before submission. Proper verification ensures claims are accurate, complete, and compliant with Nevada Medicaid rules, reducing administrative delays and recoupments.

For more details about our exceptional OBGYN medical billing services in Nevada, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472.

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