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OB/GYN Billing & Coding Guidelines
Numerous practices have encountered difficulties with OB/GYN billing and coding due to the constant changes in CPT codes and ICD-10 implementation. This has led to an increase in claim denials and a decrease in practice revenue. The updating coding requirements demand gynecologists to stay notified of significant general changes. It allows physicians to accurately record and maintain patient histories. The payment received can be optimized by handing over the OB/GYN billing process to an experienced team. For optimized payment collection for delivered services, allow experts and experienced teams to handle your OB/GYN billing.
Managing OB/GYN medical billing is not an easy task. However, a good understanding of Current Procedural Terminology (CPT) codes can have an impact on one important aspect of your practice. That aspect is “payment”.
Obstetrics and Gynecology/Maternity care services include:
- Antepartum care
- Delivery services
- Postpartum care
Best Obstetrics Billing and Coding Practices
OB coding has never been an easy job. However, considering the following important basics can help add more accuracy to your claims:
- Since every plan is different, comprehend the details provided in the payer’s billing guidelines regarding antepartum care, deliveries, and global codes. For instance, while choosing Medicaid HMO plans, you must bill deliveries using non-standard codes.
- Patients have multiple medical bills to pay for the delivery, therefore, generate an “OB Contract” for them. The contract will state the patient’s share of the delivery claim. This gives them more price transparency and up-front estimates, and a sense of security. It also allows them to make payments before delivery.
- Maternity care must be coded using global codes. Avoid duplication of bills for services covered in these codes.
- Use distinctive E/M codes that are applicable. These codes can be used for services other than maternity care.
Global Obstetric Care
The services covered in the obstetric care package are antepartum care, delivery services, and postpartum care. Any healthcare practitioner, belonging to the same or different specialty, who offers the entire OB package, must use the Global OB package code.
Global OB CPT Codes
- 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.
OB Global Billing Guidelines
Global maternity allowance is paid as a complete and single-time bill. Professional services for routine antepartum care, delivery services, and postpartum care are included in the global maternity allowance.
The payment for all services of the patient’s obstetric care is reimbursed to one provider.
If the patient visits her provider for prenatal care more than four times before delivery, and the provider proceeds with the delivery and postpartum care, he/she must bill the Global OB code.
After delivery, the Global maternity billing can continue for the next 42 days with the release of care. The billing of Global OB care can only be done after the delivery date or on the delivery date.
Services Included In Global Obstetrical Package
The Global package is a set of services that need a thorough understanding. It is important to know what is included and excluded in the services.
The Global package covers three areas. All services provided to the patients fall into these areas. The services are as follows:
Antepartum care: Includes the care provided from conception until the delivery of the fetus.
Intrapartum care: Includes inpatient care of the passage of the fetus and placenta from the womb.
Postpartum care: Includes the care provided to the patient after fetus delivery.
Antepartum Care
Antepartum care involves initial and subsequent prenatal history and examination. This comprises:
- All standard prenatal appointments (up to 13 patient visits) – Till the birth
- Monthly check-ins – Till 28 weeks of gestation
- Biweekly appointments – Till 36 weeks of gestation
- Weekly visits – From 36 weeks until delivery
- Recording weight, blood pressure, fetal heart tones
- Consultation for exercise and nutrition during pregnancy
- Routine chemical urinalysis (CPT codes 81000 & 81002)
- Educating about pregnancy, lactation, and breastfeeding (Medicaid patients)
NOTE: Any services or visits within this duration that are not related to pregnancy shall be coded separately.
Intrapartum Care
Intrapartum care involves delivery and labor time. It consists of:
- Patient’s history and physical checkup upon admission to the hospital
- Inpatient evaluation and management (E/M) services that are offered within 24 hours of delivery
- Fetal observation and uncomplicated labor management
- Induction or administration of oxytocin intravenously is performed by the provider
- Vaginal, cesarean section delivery, delivery of placenta only (the operative report)
- Insertion of a cervical dilator on the same date as to delivery, artificial rupture of membranes, placement catheterization, or catheter insertion.
Postpartum Care
Postpartum care consists of the following:
- Uncomplicated inpatient visits followed by delivery
- Repair of first-degree or second-degree lacerations (refer to “Services included in the Global OBGYN Package” for lacerations of the third or fourth degree)
- Basic cerclage removal (not under anesthesia)
- Routine outpatient E/M services provided within six weeks after delivery (check the insurance guidelines for the postpartum period)
- Discussion on contraception before discharge
- Postpartum outpatient treatment
- Educating about lactation, breastfeeding, and basic newborn care
- Provision of simple remedies and care for nipple issues and infection
NOTE: The above-stated points shall be billed using only one CPT code. Using separate CPT codes in Global Package is not appropriate.
Services Excluded From Global Obstetrical Package
Few OB/GYN care procedures are complicated, and may not be required for all patients. Thus, to make OB/GYN billing less complex, most patients and providers suggest the exclusion of these procedures from the Global Package.
The global package dismisses some procedures that are compiled by the American College of Obstetricians and Gynecologists (ACOG).
The Global Package does not include some procedures. In case the provider performs the below-listed procedures during pregnancy, he/she should opt for separate billing.
- Initial E/M for the diagnosis of pregnancy in case the antepartum documentation has not begun at this confirmatory visit
- Mostly done in the first 12 weeks before the ACOG antepartum note starts. CPT Category II code 0500F is used for this.
- ICD-10-CM diagnosis code Z32.01 supports this confirmation visit (amenorrhea).
- Laboratory tests (this excludes routine chemical urinalysis)
- Some examples are HIV testing, liver functions, CBC, Blood glucose testing, antibody screening for Hepatitis or Rubella, sexually transmitted disease screening, etc.
- Pregnancy ultrasound, NST, or fetal biophysical profile
- All following ultrasounds after the first three consider bundled depending on the insurance carrier.
- Fetal Maternal or echography procedures
- Fetal contraction stress test
- Cerclage, or the placement of a cervical dilator for more than 24 hours after admission
- Amniocentesis
- Amnioinfusion
- Inpatient E/M services provided for over 24 hours before delivery
- External cephalic version (baby’s movement due to malposition)
- Surgical Procedures during pregnancy
- Chorionic villus sampling (CVS)
- ACOG coding guidelines recommend reporting this using modifier 22 of the CPT code.
- Examples include the urinary system, nervous system, cardiovascular, etc.
- Contraceptive management services (insertions)
- During delivery, laceration repair of a third-degree or fourth-degree
OBGYN Billing Services CPT Code List
The AMA categorizes CPT codes for delivery and maternity care. The full list of all potential CPT codes for pregnant women at full term listed below;
NOTE: This list does not include pregnancy-related complications such as incomplete or missed abortions and pregnancy terminations.
The 2022 CPT codebook also contains the following codes.
CPT
Description
Package
59400
Routine OB GYN care, including antepartum care, vaginal delivery (with or without episiotomy and forceps), and postpartum care
Global Package CodeVaginal Delivery
59409
Vaginal delivery only (with or without episiotomy and forceps);
Itemization Code
59410
Vaginal delivery only (with or without episiotomy and forceps); including postpartum care
Itemization Code
E/M
Antepartum care only; 1-3 visits
Itemization Code28
59425
Antepartum care only; 4-6 visits
Itemization Code
59426
Antepartum care only; 7 or more visits
Itemization Code
59430
Postpartum care only (separate procedure)
Itemization Code
59510
Routine OBGYN care, including antepartum care, cesarean delivery, and postpartum care
Global Package Code C-Section Delivery
59514
Cesarean delivery only;
Itemization Code
59515
Cesarean delivery only; including postpartum care
Itemization Code
59610
After previous cesarean delivery, routine OBGYN care, including antepartum care, vaginal delivery (with or without episiotomy or forceps), and postpartum care.
Global Package Code VBAC Delivery
59612
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and forceps);
Itemization Code
59614
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and forceps); including postpartum care
Itemization Code
59618
Routine OB GYN care, including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery
Global Package CodeVBAC Delivery
59620
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;
Itemization Code
59622
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, including postpartum care.
Itemization Code
High-Risk Pregnancies CPT Code List for OBGYN Medical Billing
High-risk pregnancies can lead to health issues for the mother and/or baby before, during, or after delivery. Such situations demand increased attention throughout pregnancy and often require over 13 prenatal visits.
The following can cause a high-risk pregnancy case:
1) Maternal age is a significant factor. The risks of pregnancy multiply for mothers who conceive after the age of 35.
2) Pregnancy risks might increase due to pre-gestational medical complications, such as:
- Diabetes
- Hypertension
- Epilepsy
- Blood or heart conditions
- Thyroid disease
- Poorly-controlled asthma
- Infections
Some of the complications that may arise during pregnancy are:
- Gestational diabetes
- Hypertension
- Stunted fetal growth
- Preterm membrane rupture
- Improper placenta position
Patients with such pregnancy complications need more intensive patient care than patients with normal pregnancies. Therefore, high-risk pregnancy patient visits are different, and must be reported in addition to the global OBGYN billing codes; 59400, 59510, 59610, and 59618.
The claim must include a proper high-risk or difficult diagnosis code. Thus, if the provider offered intense care to a high-risk pregnancy patient, he/she may submit extra E/M codes and modifier 25.
High-Risk Pregnancies ICD-10 Codes for OBGYN Billing Services
Following are the ICD-10 codes used for high-risk pregnancies in OBGYN Medical Billing Services:
| ICD-10-CM | Description |
|---|---|
| O09.899 | Supervision of other high-risk pregnancies |
| O10.119 | Pre-existing hypertensive heart disease complicating pregnancy |
| O11.9 | Pre-existing hypertension with pre-eclampsia |
| O12.20 | Gestational [pregnancy-induced] edema and proteinuria without hypertension |
| O11.4 | Pre-eclampsia |
| O24.011 | Pre-existing type-1 diabetes mellitus, in pregnancy |
| O26.61 | Liver and biliary tract disorders in pregnancy |
| O99-019 | Anemia in pregnancy |
Ultrasound OB/GYN MEDICAL Billing
The reporting of ultrasounds must be done by closely following the requirements of maternity care OBGYN billing and coding.
The provider must have a written report along with pictures. According to AMA CPT and ultrasound documentation requirements, all diagnostic and procedure guidance ultrasounds require image retention.
For every coded procedure, the appropriate images that show the relevant anatomy/pathology should be open for review. The medium for the storage of images is not specified by CPT.
Given that there are multiple fetuses and various procedures performed, modifiers will be applicable. Reporting a wrong modifier may lead to claim denial.
The potentially carried-out ultrasounds may be reported using the following CPT codes. Each CPT code should be assigned by thoroughly comprehending the guidelines.
76801–76810: Maternal and Fetal Evaluation (Transabdominal Approach, By Trimester)
76811–76812: Above and Detailed Fetal Anatomical Evaluation
76813–76814: Fetal Nuchal Translucency Measurement
59025: Fetal Non-Stress Test
76818–76819: Fetal Biophysical Profile
76815: Limited Trans-Abdominal Ultrasound Study
76816: Follow-Up Trans-Abdominal Ultrasound Study
76817: Trans-Vaginal Ultrasound Study
The OBGYN coder must understand the instructions to properly bill the services for multiple gestations and ultrasounds.
BillingFreedom OBGYN Medical Billing Services
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BillingFreedom has a highly-qualified team for revenue cycle management services that are fully aligned with CMS guidelines. Our services have been successfully fulfilling the billing requirements for certain conditions. Following are the few states where our services have taken on a priority basis to cater to billing requirements.
Gynecology Coding Best Practices
If you’re working on the ‘GYN’ side of OB/GYN, there are other best practices you’ll need to keep in mind.
Hysterectomies
A hysterectomy is a surgery performed to remove the uterus. The procedure for a hysterectomy requires the consideration of unique coding and billing practices. The CPT code used depends on:
- The approach to the surgery, which includes abdominal, vaginal, and laparoscopic approaches
- The weight of the uterus
- The extent of the surgery, i.e. the proportion of the removed uterus
The added procedures and services for hysterectomy factor in for some CPT codes.
- 58150-58210: Abdominal hysterectomy
- 58260-58291: Vaginal hysterectomy
- 58541-58573: Laparoscopic hysterectomy
Well-Woman Visits
Well-woman visits are annual check-ups taken by women with their OB/GYN. The extent of these visits can range from general health screening to cervical cancer screening.
Well-woman exams are coded based on two factors:
- Patient’s age
- New or returning patient
- 99385-99387: New patient
- 99395-99397: Existing patient
Modifiers
The CPT codes of OB/GYN usually contain modifiers at the end of the code. Modifiers can be defined as a 2-digit code that helps identify the alteration in service of the 5-digit CPT code. View the cheat sheet *link* for the common modifiers used for OB/GYN.
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