Coding for Maternity Services When Total (or Global) Obstetrical Care is Not Provided

Routine obstetrical services are generally provided by the same physician or his partners in the same practice, or his other covering physicians as he so designates. The maternity global fee begins with the confirmation of pregnancy by urine or blood test and ends at the completion of monitoring for the postpartum period, which is generally a six week period of time.

The codes below are not considered global codes and should not be billed in addition to global Physicians’ Current Procedural Terminology (CPT) codes. However, these codes may be used in situations such as when the patient changes physicians (i.e. moves out of town or changes to another obstetrical (OB) doctor in the same town, different practice), or when the pregnancy is terminated (i.e., miscarriage or abortion) or the patient’s Blue Cross insurance coverage terminates. In these situations, each physician providing services bills for the services he renders and is reimbursed according to the terms of the patients’ contract and in accordance with the Preferred Medical Doctor (PMD) fee schedule. The combined total payment is split between each physician rendering care for the patient during a single pregnancy. The payment will not exceed the allowance for the global obstetrical care. These codes may initially reject for payment. If that occurs, the provider should contact customer service and identify the circumstances for which the non-global claim was filed. This is essential for the claim to be correctly reprocessed.

The following codes are not considered global codes:

                                 
The following codes are considered global codes:                                                                       

During routine maternity care, global codes include up to two medically necessary ultrasounds (including the emergency department) plus postpartum and antepartum care. Additional ultrasounds may be considered medically necessary for non-routine (high risk) conditions. Click here to view the Blue Cross medical policy on ultrasounds in maternity care. Only in the situations outlined above under “Not Global Codes” should the provider bill for evaluation and management (E&M) codes. Otherwise, with global billing, E&M codes are considered part of the global reimbursement. There are few exceptions when benefits are provided for office visits within the six weeks global period. Global care excludes laboratory services.

There are many diagnosis codes that are considered routine and are used when filing routine global services. Most of these codes are either “V” or “600” series codes. There is no list which identifies these diagnosis codes. Providers should always code to the highest degree of certainty and have clinical documentation in the medical record that would support billing.

Waiting periods generally do not apply for maternity. Please check eligibility and benefits for verification. Each maternity admission is covered for an inpatient stay of up to 48 hours for a vaginal delivery and up to 96 hours for a C-section delivery. Hospital stays beyond these times may be reviewed for medical necessity.

Please review eligibility and benefits to determine whether coverage is available for dependent pregnancies, as some contracts exclude this coverage.

When a patient’s coverage changes due to a move from one group to another and the groups are not associates with each other (i.e., they are not subsidiary companies), services received up to the cancel date would be processed under the existing group plan. Services received after the cancel date of the old group plan should be billed under the new group plan.

Last Updated March 2010