Reimbursements

Category:

Global Maternity

Reimbursement Policy: NDRP-GC-021
Topic: General Coding
Effective Date: October 31, 2019
Last Reviewed:
October 31, 2019

Description:

This policy is to provide direction on global maternity care which includes pregnancy-related antepartum care, admission to Labor and Delivery, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care until six weeks postpartum. The following antepartum services are not considered a part of global maternity care such as laboratory tests (excluding dipstick urinalysis), diagnostic ultrasound, amniocentesis, cordocentesis, chorionic villus sampling, fetal stress test, and fetal non-stress test and are eligible to be reimbursed separately.

 

Billing for Maternity Care:

Global Maternity Coverage

 Normally, a provider should file global maternity care when they provide prenatal care, labor and delivery and postpartum care.

Prenatal, Delivery and/or Postpartum Services Billed Separately

It would be appropriate for the provider to file prenatal, delivery and/or postpartum services separately if:

      • The member’s coverage started after the onset of pregnancy
      • The coverage terminates prior to delivery
      • The pregnancy does not result in delivery
      • Another provider in a different practice assumes care of the member prior to completion of global services
      • During the member’s pregnancy, there was a change in the member’s benefit package or certificate number due to an employer change only

 

Multiple Births:

Vaginal deliveries only

    • Baby A: File the appropriate “global vaginal delivery” code. (Reimbursed at 100% of the allowable.)
    • Babies B and beyond: File appropriate “vaginal delivery only” code with modifier – 59 If more than one subsequent baby is delivered, the total number of babies B and beyond should be indicated in the units field. (Reimbursed at 50% of the allowable each for Babies B and beyond.)
    • If antepartum and/or postpartum care were not provided, then report only the appropriate “vaginal delivery only” code, reflecting the total number of deliveries in the units fields for Babies A and beyond (Reimbursed at 50% of the allowable for Babies B and beyond.)
    • If antepartum care was not provided but postpartum care following hospital discharge was provided, report appropriate code for “vaginal delivery only including postpartum care” for Baby A. Report the appropriate “vaginal delivery only” code for Babies B and beyond with modifier -59 If more than one subsequent baby is delivered, the total number of babies B and beyond should be indicated in the units field. (Reimbursed at 50% of the allowable each for Babies B and beyond.)

 Cesarean delivery only

    • Baby A and beyond: File only once for appropriate “global Cesarean delivery” code. (Reimbursed at 100% of the allowable.)
    • If antepartum and postpartum care were not provided, then report only once the appropriate “Cesarean delivery only” code.
    • If antepartum care was not provided but postpartum care following hospital discharge was provided, then report only once the appropriate “Cesarean delivery only; including postpartum care” code.
    • “Global Cesarean delivery,” “Cesarean delivery only,” and “Cesarean delivery only; including postpartum care” codes should be reported only once regardless of the number of babies delivered.

  Vaginal delivery, followed by Cesarean delivery

    • Baby A: File appropriate “vaginal delivery only” code with modifier -59 appended. (Reimbursed at 50% of allowable.)
    • Baby B and beyond: File appropriate “global Cesarean delivery” or “Cesarean delivery only” code once. (Reimbursed at 100% of allowable.) When global care was also provided, the global service is applied to the Cesarean delivery as the intrapartum work and postpartum care is more pertinent to a Cesarean delivery than a vaginal delivery.
    • If antepartum care was not provided, but postpartum care following hospital discharge was provided, code the appropriate code for “vaginal delivery only” for Baby A with modifier -59 (Reimbursed at 50% of allowable.) Report the appropriate “Cesarean delivery only; including postpartum care” code once for Babies B and beyond. (Reimbursed at 100% of allowable.)
    • “Global Cesarean delivery,” “Cesarean delivery only,” and “Cesarean delivery only; including postpartum care” codes should be reported only once regardless of the number of babies delivered.

 

Ultrasounds – Twin Pregnancy:

When an ultrasound is performed on a woman who is pregnant with twins, code 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [< 14 weeks, 0 days]), transabdominal approach; single or first gestation) should be reported for the first twin. The ultrasound for the second twin should be reported using code 76802 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [< 14 weeks, 0 days], transabdominal approach; each additional gestation).

 

Fetal Non-Stress Test:

Twin Pregnancy

A fetal non-stress test is a non-invasive diagnostic procedure performed on the mother, but the patient is actually the fetus. According to the AMA, it is appropriate to code 59025 for each fetus. For a twin gestation, 59025 would be billed twice with modifier 59 on the second code to indicate a distinct, separate procedure. The medical record must reflect additional tests were ordered, performed and the result of each test.

An appropriate ICD-10-CM diagnosis code identifying a multiple gestation pregnancy is required.

Fetal Non-Stress Test and Fetal Biophysical Profile

It is not appropriate to report code 59025 (Fetal non-stress test) in conjunction with code 76818 (Fetal biophysical profile; with non-stress testing) for the same date of service.

CPT® code 76818 is used to assess the physiologic status of the fetus. To report this code, all five of these elements must be performed:

      1. Fetal trunk and extremity movement
      2. Fetal tone
      3. Fetal breathing movement
      4. Amniotic fluid volume
      5. Fetal non-stress test

Since a fetal non-stress test is already included in the required elements for code 76818, code 59025 should not be reported separately for the same date of service.

 

Services Unrelated To Pregnancy:

Services unrelated to pregnancy but performed by the provider rendering global maternity care should be documented and reported separately with the appropriate inpatient or outpatient Evaluation and Management code, using the condition unrelated to pregnancy as the primary diagnosis code.

  

Referral to Perinatologist:

When a member is referred to and evaluated by a perinatologist, that perinatologist should bill an Evaluation and Management Consultation Code with the problem diagnosis that necessitated the referral. Maternity health status codes should not be used, as they may cause the visit to be attributed to global maternity care.

 

Quality Reporting:

 In support of quality tracking and in accordance with HEDIS guidelines, we encourage that claims (in addition to the global billing claim) be submitted for the following:

  •  Date of first prenatal visit: Submit a claim reflecting the actual date of the first visit for prenatal care. Use CPT Category II code 0500F (Initial prenatal care visit) or 0501F (Prenatal flow sheet documented in medical record by first prenatal visit)
  •  Date of postpartum visit: The postpartum visit should occur 4-6 weeks after delivery. Submit a claim with the actual date the postpartum service was rendered. Use CPT Category II Code 0503F (Postpartum care visit).
  •  Date of last menstrual period (LMP): Box 14 of the CMS 1500 Claim Form

 

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

 

Cross-Reference:

The Current Procedural Terminology (CPT) Manual

Global Maternity & Multiple Birth Billing Cheat Sheet

 

History:

Date Updates
10/31/2019  Created new reimbursement policy and archived HCN #388 – Maternity Care and Delivery

 


Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.