Reimbursement Policy Maternity Services
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Defines Amerigroup's reimbursement rules for global obstetrical codes and component maternity services (antepartum, delivery, postpartum) for providers billing under the same TIN; applies to provider claims submitted to Amerigroup per member benefit plans.
No material clinical or coverage changes in this revision.
Global Package Coverage
Global package inclusions and exclusions
Coverage stance on the global obstetrical package and which services are included in or may be billed separately from the global package when billed by a single provider or provider group under the same TIN.
Included in the global package (not separately reimbursable when any CPT code for global services is billed):
- Initial and subsequent history and physical exams when a pregnancy diagnosis has already been established.
- All routine prenatal visits until delivery (typically 13 visits).
- Additional visits for a high-risk pregnancy, potential problems, or history of problems that do not actually develop or are inactive in the current pregnancy.
- Collection of weight, blood pressure, and fetal heart tones.
- Routine urinalysis.
- Admission to the hospital, including history and physical.
- Inpatient Evaluation and Management (E/M) services that occur within 24 hours of delivery.
- Management of uncomplicated labor (including administration of labor-inducing agents).
- Insertion of cervical dilators on the same date of the delivery.
- Simple removal of cerclage.
- Vaginal (including forceps or vacuum-assisted delivery) or cesarean delivery of single gestation.
- Delivery of placenta.
- Repair of first- or second-degree lacerations.
- Uncomplicated inpatient visits following delivery.
- Routine outpatient E/M services within 6 weeks of delivery.
- Discussion of contraception.
- Postpartum care only.
- Education on breastfeeding, lactation, exercise, or nutrition (when part of global services).
Not included in the global package (may be billed separately):
- Initial E/M visit to diagnose pregnancy when antepartum activities are not initiated.
- Laboratory testing (excluding routine urinalysis).
Additional antepartum E/M visits for active high-risk complication:
- Additional antepartum E/M visits in excess of 13 may be billed separately only at the time of delivery with modifier 25 and an appropriate high-risk diagnosis.
- Additional E/M visits for conditions unrelated to pregnancy (may be reported as they occur and must be clearly not related to pregnancy).
- Maternal or fetal echocardiography procedures.
- Amniocentesis.
- Chorionic villus sampling.
- Fetal contraction stress testing and nonstress testing.
- Biophysical profile.
- Amnioinfusion.
- Insertion of cervical dilator that occurs more than 24 hours before delivery.
- Inpatient E/M encounters that occur more than 24 hours before delivery.
- Management of surgical problems arising during pregnancy.
- Care provided by maternal-fetal medicine specialists.
- Ultrasound (see Maternity Ultrasound in the Outpatient Setting Medical Policy).
- External cephalic version.
- Education on breastfeeding, lactation, exercise, or nutrition (when billed separately from global services).
Coding and Modifiers
| Standard correct coding applies; diagnosis codes indicating outcome of delivery and gestational weeks are required on professional delivery service claims. |
| modifier 25 | Use when submitting additional antepartum E/M visits (in excess of 13) for a high-risk complication; submit at time of delivery with an appropriate high-risk diagnosis. |
Documentation, Billing and Denials
Documentation and billing requirements
Providers should use the appropriate E&M codes for antepartum and postpartum care; Amerigroup may request medical documentation to perform a post‑pay review of paid claims. Providers are required to include a diagnosis code indicating outcome of delivery on professional delivery service claims and diagnosis codes that indicate gestational weeks on all professional delivery service claims; failure to report the appropriate diagnosis code will result in denial. Claims must use industry‑standard CPT, HCPCS, and/or revenue codes and be fully supported in the medical record; Amerigroup may reject, deny, recoup, or adjust payment if coding/billing guidelines or reimbursement policies are not followed.
- Use appropriate E&M codes for antepartum and postpartum services.
- Include outcome of delivery diagnosis on professional delivery claims.
- Include gestational weeks diagnosis codes on all professional delivery claims (recommended for other pregnancy‑related claims).
- Retain medical records to support billed services; Amerigroup may request documentation for post‑pay review.
- Bill with appropriate CPT, HCPCS, and/or revenue codes; noncompliance may result in claim denial, recoupment, or payment adjustment.
Duplicate or overlapping service denials and recoupment risk
Claims for overlapping or duplicate global, delivery, antepartum, or postpartum services may be denied or may cause previously paid overlapping claims to be recouped; if a global or component service has already been paid for the same pregnancy, related subsequent claims may be denied or subject to recovery.
- Global obstetrical codes are allowed once per pregnancy period; duplicate or overlapping services during the pregnancy will not be reimbursed.
- Delivery‑only, delivery/postpartum, antepartum‑only, or postpartum‑only claims may be denied if global or overlapping services for the same pregnancy have been paid.
- Assistant surgeon reimbursement for delivery‑only services applies only for cesarean deliveries with the appropriate modifier.
Key Definitions
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