Coding and Billing Maternity Care When a Patient Changes Insurance

Coding and Billing Maternity Care When a Patient Changes Insurance

To bill “normal, uncomplicated” maternity care, report a single CPT® code, based on the 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 previous cesarean delivery

If the physician does not perform all services described by the global codes (for example, the patient receives irregular or late prenatal care, experiences a miscarriage or terminates a pregnancy, or changes providers during the pregnancy), you may report delivery, antepartum care, and postpartum care independently of one another, using dedicated codes. CPT® maternity care guidelines (and related CPT Assistant articles) give ample guidance to apply these maternity care codes correctly, in most situations.

The Switch

There’s a common maternity care coding and billing scenario that CPT® guidelines do not address: The patient switches insurance during the pregnancy, but keeps the same physician.

In such a case, proper billing will depend on the payer. As a general rule, each insurer will pay only for that exact portion of care for which it is responsible. To illustrate, the following guidance is taken from the Health Reimbursement Policy of Moda Health, a private insurer in Alaska, Oregon, and Washington:

The patient presents to your clinic for obstetrical care in the 8th week of her pregnancy. She is seen monthly, and in her 21st week she has a change of insurer. She continues to be seen monthly for the remainder of her first 28 weeks, then biweekly to 36 weeks, and then weekly until her delivery at 39 weeks for a total of 13 visits. The clinic performs the vaginal delivery and provides the postpartum care.

The billing office bills the first four visits to carrier A with 59425 [Antepartum care only; 4-6 visits] using the date of the first visit as the From date and the date of their last visit before the change in insurance as the To date. The additional nine visits are billed to carrier B with 59426 [Antepartum care only; 7 or more visits]. This claim also bills the delivery and postpartum care with 59410 [Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care]. The delivery date should be used as the date of service for all services on both claims.

There may be exceptions to this rule. For example, if the patient delivers late or has multiple “worried well” visits from the point she switched insurance, the requirements of insurance “B” might be met, and global billing (e.g., 49400)—not itemized billing—may be warranted. This is a gray area, so contact the responsible payer for instruction, prior to billing.

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One Response to “Coding and Billing Maternity Care When a Patient Changes Insurance”

  1. Tameka says:

    This is a good read, but I am confused about one part and I’m not sure if I’m reading it right.

    I understand that carrier A will be billed 59425 and the date of the first visit as the From date and the date of their last visit before the change in insurance as the To date, but what I am confused about is why it says “the delivery date should be used as the date of service for all services on both claims.”

    I would bill carrier B 59426 with the date of the first visit after the effective date of the new carrier being the From date and the date of the last visit before delivery as the To date. Then I would bill the 59410 with the delivery date as both dates.

    Please clarify and correct me if I misunderstood.

    Thanks!

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