From Antepartum to Postpartum, Get the CPT® OB Basics
Simplify coding by knowing what is packaged into obstetrics care.
By Dawson Ballard, Jr., CPC, CEMC, CCS-P
Coding for obstetric (OB) services can be complicated. When reporting maternity care, you must know what is included in the global OB package. Per CPT® guidelines, the global OB package includes “uncomplicated care” to the patient in the antepartum period, the delivery, and through the postpartum period.
Let’s begin by examining the antepartum period, delivery, and postpartum period separately. Then, we’ll discuss proper coding when the physician provides all three (e.g., global maternity care).
CPT® defines antepartum care as beginning with conception and running through delivery. The following services are inclusive to antepartum care (and inclusive to the global OB package), and are not separately reportable:
- Obtaining the patient history (including the initial history and any subsequent history)
- The exam
- Obtaining and recording the weight, blood pressures, and any fetal heart tones
- Routine chemical urinalysis
- Monthly visits up to 28 weeks gestation
- Bi-weekly visits up to 36 weeks gestation
- Weekly visits up to delivery
The following services usually occur during antepartum care, but are not inclusive to the global OB package, and may be reported separately:
- Complications of the pregnancy
- Evaluation and management (E/M) services for problems unrelated to the pregnancy
- Lab tests performed outside of routine chemical urinalysis, including venipuncture
- Surgical complications or other problems related to the pregnancy
- Chronic villous sampling
- Fetal stress testing
- Fetal non-stress testing
- OB ultrasounds (limited or complete)
- Fetal biophysical profile
- Fetal electrocardiography
- RH immune globulin administration
Antepartum Care-only Reporting
Antepartum care only does not include delivery or postpartum care. When reporting this service, you do not report the global maternity package. These circumstances occur commonly in the OB world. Examples are if the patient changes insurance payers during the maternity care, if the patient transfers care to another provider, or if the patient miscarries or aborts the fetus.
In most circumstances, the average number of antepartum visits for uncomplicated care is 13. Antepartum visits totaling fewer than 13 should be reported separately from the OB package using codes for antepartum care only. If circumstances warrant reporting antepartum services only, code selection is based on the total number of provided antepartum visits.
- If four to six visits are provided, report 59425 Antepartum care only; 4-6 visits.
- If seven or more visits are provided, report 59426 Antepartum care only; 7 or more visits.
When reporting antepartum care, claim the correct code only once. For example, a physician provides eight antepartum visits to a patient. After the eighth visit, the patient changes insurance carriers. The eight visits prior to the insurance change are separately reportable to the initial payer. To code this scenario correctly, the physician reports 59426 (one unit).
If only one to three antepartum visits were provided, report the appropriate E/M codes, according to CPT® guidelines. For example, a provider performs one antepartum visit to an established patient. The visit includes an expanded, prob-lem-focused history and exam, with medical decision-making (MDM) of low complexity. Prior to a second visit, the patient suffers a spontaneous abortion. To code this scenario correctly, based on the key components and the patient’s status, the provider reports E/M code 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.
Delivery codes include admission to the hospital, the hospital history and physical, the exam, and management of un-complicated labor. Any E/M services provided within 24 hours of delivery are also included (E/M services that occur more than 24 hours of the delivery may be separately reported). All inpatient E/M services and postpartum services are also included in the delivery codes.
The delivery codes also include:
- Inducing labor using pitocin or oxytocin
- Injecting anesthesia
- Artificial rupturing of membranes that occur prior to delivery
- Inserting a cervical dilator for vaginal deliveries, if the insertion occurs on the same date as the delivery. If the insertion occurs on a separate date from the delivery, the insertion is separately reportable.
- Delivery of the placenta is also included unless it occurs at a separate encounter from the delivery of the baby. An example of this would be when a patient delivers her baby enroute to the hospital and, following admission, the provider delivers the placenta. In this case, the delivery of the placenta may be separately reported.
- Repair of any minor lacerations (i.e., first or second degree). If extensive lacerations (i.e., third or fourth degree) must be repaired, modifier 22 Increased procedural services may be appended to the delivery code. If lacerations are repaired by a provider who is not the attending, CPT® guidelines direct that code 59300 Episiotomy or vaginal repair, by other than attending physician may be reported by the provider repairing the lacerations.
Services that are excluded (or not inclusive) of the delivery code, and may be reported separately, include:
- Scalp blood sampling on the newborn
- External cephalic version
- Administration of anesthesia such as an epidural
Delivery or Delivery with Postpartum Care-only Coding
If a provider performs the delivery only, and provides no antepartum or postpartum care, code selection depends on the type of delivery:
59409 Vaginal delivery only (with or without episiotomy and/or forceps)
59514 Cesarean delivery only
59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)
59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery
Because delivery only is performed, and the provider is not performing the entire global maternity package, any inpatient E/M visits related to the delivery are separately reported.
Example: A patient presents to the hospital at 39 weeks gestation in the early onset of labor. The patient delivers a fe-male infant vaginally with the help of her primary obstetrician/gynecologist (OB/GYN). The patient develops a third-degree vaginal laceration during the delivery that is repaired by the OB/GYN. In total, the patient’s OB/GYN performs 14 antepartum visits, the delivery, and all postpartum care.
To correctly report this scenario, the physician will report 59400-22 for the global maternity care. Repair of minor vaginal lacerations are included in the delivery, but extensive lacerations may be reported by appending modifier 22 to the global code. In this case, the patient developed a third-degree laceration, which is considered major.
If a provider assists the patient’s primary OB/GYN with the delivery, and is claiming no antepartum or postpartum care, report the appropriate delivery-only CPT® code and append modifier 80 Assistant surgeon.
Example: Dr. A is the patient’s primary OB/GYN. The patient presents to the hospital in labor. The delivery appears to be complicated. Dr. B, who is on call with the hospital, is called in to assist Dr. A. The patient delivers a health baby girl via VBAC. Because Dr. B only assisted with the delivery (she provided no antepartum care and Dr. A is providing all postpartum care), her services are reported with 59612-80.
If the provider performs the delivery and also plans to provide postpartum care (but he or she did not provide any ante-partum care), CPT® specifies the following codes, based on the type of delivery:
59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care
59515 Cesarean delivery only; including postpartum care
59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care
59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care
Example: A patient delivers a male infant via cesarean. The patient does not have a primary OB/GYN and has had no antepartum care. The physician performs the cesarean and orders the patient to follow up in his office for postpartum care in two weeks, which the patient does. To correctly code this encounter, the physician reports 59515.
Per ICD-9-CM guidelines, postpartum care starts immediately after delivery and runs for six weeks. Check with the payer for its specific policies on postpartum care, as policies may vary. For example, CIGNA® allows six weeks postpartum care for vaginal deliveries, but extends the period to eight weeks for cesarean deliveries.
If the provider is reporting the global maternity package, all postpartum visits are included in the global code. If the provider is not claiming the global maternity package, and is providing postpartum care only, report 59430 Postpartum care only (separate procedure). This code includes all after-delivery E/M visits related to the pregnancy.
Example: A patient vaginally delivers a healthy infant. The patient moves to another town immediately following her delivery, and presents to a new OB/GYN provider for postpartum care. Because the new OB/GYN is providing only postpartum care, proper coding is 59430.
Coding Global Maternity Care
If the provider may report routine global maternity care (which includes antepartum care, delivery, and postpartum care), do not report three separate codes. Instead, report a single code, based on the type of delivery:
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 pre-vious cesarean delivery
Check with your specific third-party payers before reporting the global OB package, as payer policies on what is included in the global package may differ.
Complications of Pregnancy, Unrelated Issues
If a patient develops complications of pregnancy or the provider treats the patient for an unrelated problem, these visits are excluded from the maternity global package and can be reported separately. Append modifier 24 Unrelated evaluation and management service by the same physician during the global period to all E/M services that address the pregnancy complications or unrelated issues. Modifier 24 is needed to alert the carrier that the E/M service(s) is unrelated to the global OB package (for a detailed explanation, see “Related or Not? Pass the Modifier 24 Paternity Test” on page 24).
Example: An established patient at 22-weeks gestation is admitted to hospital observation with pre-term labor. The pa-tient’s OB/GYN visits the patient in observation and performs a comprehensive history, exam, and MDM of moderate complexity. The next day, the OB/GYN returns and determines the patient has improved. The patient is discharged from observation care with orders to follow up in the OB/GYN’s office in one week. Correct coding for these encounters:
99219-24 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity.
99217-24 Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from “observation status” if the discharge is on other than the initial date of “observation status.”
Remember: The global maternity package includes uncomplicated care. Because this patient was diagnosed with pre-term labor and admitted to observation, this is not uncomplicated care and, thus, it is separately reportable with the observation E/M codes. Modifier 24 is needed to indicate these encounters are unrelated to the global maternity package.
Dawson Ballard, Jr., CPC, CEMC, CCS-P, is a coder at Town Plaza OBGYN in Overland Park, Kan., and a member of the Overland Park local chapter.
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