CurrentAnthemPolicy G-14001

Maternity Services Reimbursement Policy

Governs reimbursement rules for global obstetrical and related maternity service billing for Anthem Medicare Advantage members in California, specifying when global codes may be billed and which elements are included or excluded.

Policy Summary

PayerAnthem

PolicyMaternity Services Reimbursement Policy

Policy CodePolicy G-14001

Change TypeNo material change

Effective Date07/07/2023

Next Review Date

Key ActionAnthem may request medical documentation for post-pay review; ensure services meet authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

279defined period of a pregnancy for global code allowance

13routine prenatal visits included in global package

07/07/2023last approval/effective date

Californiaapplicable state

Maternity Coverage Criteria and Billing Rules

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Allow reimbursement for global obstetrical codes once per period of a pregnancy (defined as 279 days) when appropriately billed by a single provider or provider group reporting under the same federal Tax Identification Number (TIN).

Reimbursement for the global obstetric care package is based on the antepartum, delivery, and postpartum services being provided by the billing provider or provider group under the same TIN; if not all components are provided by that billing entity, global obstetrical codes may not be used and only the elements actually provided should be billed.

Anthem will not reimburse for duplicate or overlapping services during the course of the pregnancy; claims may be denied or previously paid overlapping claims may be recouped.

If another maternity service for the same pregnancy has been paid:

Global services: If global, delivery only, delivery/postpartum, antepartum only, or postpartum only services have been paid for the same pregnancy, a claim for global services may be denied or may cause a previously paid claim for overlapping services to be recouped.
Delivery only: If global, delivery only, or delivery/postpartum services have been paid for the same pregnancy, a claim for delivery only services may be denied. Assistant surgeons may be reimbursed separately for cesarean deliveries if appended with the appropriate modifier.
Delivery/postpartum: If global, delivery only, delivery/postpartum, or postpartum only services have been paid during the same pregnancy, a claim for delivery/postpartum services may be denied or may cause a previously paid claim for overlapping services to be recouped.
Antepartum only: If global or antepartum only services have been paid during the same pregnancy, a claim for antepartum only services may be denied.
Postpartum only: Postpartum only claims may be denied if global, delivery/postpartum, or postpartum only services have already been paid during the same pregnancy.

Items included in the global package (not separately reimbursable):

Initial and subsequent history and physical exams when pregnancy diagnosis already established.
All routine prenatal visits until delivery (typically 13 visits: monthly through 28 weeks, then biweekly until 36 weeks and weekly until delivery).
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 E/M services within 24 hours of delivery; management of uncomplicated labor; delivery of placenta; repair of first- or second-degree lacerations; uncomplicated inpatient visits following delivery; routine outpatient E/M services within six weeks of delivery; discussion of contraception; postpartum care only; education on breastfeeding, lactation, exercise, or nutrition.

Services that may be billed separately from the global package:

Initial E/M visit to diagnose pregnancy when antepartum activities are not initiated.
Laboratory testing (excluding routine urinalysis).
Additional antepartum E/M visits in excess of 13 for a high-risk complication that is active in the current pregnancy — these additional visits are to be submitted for payment only at the time of delivery and must be submitted with Modifier 25 and an appropriate high-risk diagnosis.
Additional E/M visits for conditions unrelated to pregnancy (may be reported as they occur if clearly not related to pregnancy).
Maternal or fetal echocardiography, amniocentesis, chorionic villus sampling, fetal contraction stress testing, nonstress testing, biophysical profile, amnioinfusion, insertion of cervical dilator >24 hours prior to delivery, inpatient E/M >24 hours prior to delivery, management of surgical problems arising during pregnancy, care by maternal fetal medicine specialists, ultrasound per separate policy, external cephalic version.

Providers are required to use the appropriate diagnosis code on professional delivery service claims to indicate outcome of delivery and gestational weeks; failure to report appropriate diagnosis code will result in denial.

Providers should use appropriate E/M codes for antepartum and postpartum care. Anthem may request medical documentation for post-pay review and reserves the right to require authorization and medical necessity documentation as appropriate.

Obstetrical Coding and Visit Counts

Obstetrical coding notesCPT

Global obstetrical codes (CPT)	Global obstetric care package codes covering antepartum, delivery, and postpartum when all services provided by same TIN
Modifier 25	Required when billing additional antepartum E/M visits (in excess of 13) for active high-risk complication

Routine prenatal visit count — global package

Routine prenatal visits included in global packageTypically 13 visits (monthly through 28 weeks, then biweekly until 36 weeks and weekly until delivery) are included and are not separately reimbursable.

Additional antepartum visits for active high-risk complicationAdditional antepartum E/M visits in excess of 13 may be billed separately only for a high-risk complication that is active in the current pregnancy; these must be submitted with Modifier 25 and an appropriate high-risk diagnosis and submitted for payment at time of delivery.

Additional visits for inactive or potential problemsVisits for a high-risk pregnancy, potential problems, or history of problems that do not actually develop or are inactive in the current pregnancy are included in the global package and not separately reimbursable.

Routine data collection and routine urinalysisCollection of weight, blood pressure, fetal heart tones and routine urinalysis are part of the global package and not separately reimbursable.

Documentation, Review, and Billing Risk

Documentation Required

Documentation and post‑pay review

Anthem Medicare Advantage may request medical documentation for post‑pay review; services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

Medical record and/or office notes must fully support billed CPT, HCPCS, and/or revenue codes.
Services must meet authorization and medical necessity guidelines for the procedure, diagnosis, and member's state of residence.

Denial Risk

Risk of denial or recoupment for incorrect billing

Claims may be rejected, denied, or subject to recovery/recoupment if coding, billing, or current reimbursement policies are not followed.

Use industry‑standard, compliant codes on all claim submissions (CPT, HCPCS, revenue codes).
Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection, denial, or recovery/recoupment of payment.

OpenPayer

Maternity Services Reimbursement Policy

Maternity Coverage Criteria and Billing Rules

Obstetrical Coding and Visit Counts

Documentation, Review, and Billing Risk

Defined Terms