CurrentAnthemPolicy C-19004

Maternity Services - Professional Reimbursement Policy

Defines Anthem's reimbursement rules for global obstetrical codes and which maternity services are included or separately billable for commercial professional providers.

Policy Summary

PayerAnthem

PolicyMaternity Services - Professional Reimbursement Policy

Policy CodePolicy C-19004

Change TypeAdministrative and coverage clarification; new policy replacing prior routine obstetrics

Effective Date03/01/2023

Next Review Date

Key ActionProviders must follow authorization and medical necessity guidelines and may be asked to provide documentation for post-pay review of paid claims.

SourceLink

POLICY UPDATE CHANGES

Removed reference to Maternity Ultrasound in the Outpatient Setting Medical Policy and updated postpartum period for CPT 59430 to 90 days.

New Maternity Services policy (C-19004) developed to replace prior Routine Obstetrics policy (C-08005).

typically 13routine prenatal visits included in global package

2maternity ultrasounds reimbursed per pregnancy/fetus

90-daypostpartum period for CPT 59430

Maternity Services Coverage Criteria

Coverage criteria for maternity services

Covered when ALL of the following are met:

Global obstetrical codes are billed by a single provider or provider group reporting under the same federal Tax Identification Number (TIN).

All aspects of the global obstetric care package (antepartum, delivery and postpartum) are provided by the same provider or provider group reporting under the same TIN.

If all antepartum, delivery and postpartum services are not provided by the same TIN, global obstetrical codes may not be used; providers must submit for reimbursement only the elements of the obstetric package that were provided.

No duplicate or otherwise overlapping services are billed or previously paid for the same pregnancy; overlapping claims may be denied or recouped.

When Global, Delivery Only, Delivery/Postpartum, Antepartum Only or Postpartum Only services have been paid for the same pregnancy, subsequent claims for overlapping services may be denied or may cause previously paid claims to be recouped.

Delivery Only services are reimbursed to assistant surgeons only for cesarean deliveries when appended with the appropriate modifier.

Providers must use appropriate E&M codes for antepartum and postpartum care; Anthem reserves the right to request medical documentation for post-pay review of paid claims.

The global package includes routine prenatal visits (typically 13 visits), routine inpatient and outpatient care related to delivery, uncomplicated inpatient visits following delivery, routine postpartum E&M within 6 weeks of delivery, and other listed routine elements (e.g., delivery of placenta, repair of first- or second-degree lacerations, breastfeeding education).

Services not included in the global package may be billed separately (examples include initial E&M to diagnose pregnancy, laboratory testing excluding routine urinalysis, additional antepartum E&M visits in excess of 13 for an active high-risk complication with Modifier 25 and appropriate diagnosis, ultrasounds beyond two per pregnancy/fetus unless problem-oriented, amniocentesis, fetal testing, maternal-fetal medicine care, etc.).

Representative CPT Codes and Coding Details

Representative CPT codesmixedCovered

59400, 59510	Examples of global obstetric CPT codes representing total obstetrical package
59430	Postpartum care only

Covered CPT Codes - detailsCPTCovered

59430	Postpartum care only (90-day postpartum period applies).
59400, 59510	Global obstetrical package (antepartum, delivery and postpartum) — examples of global obstetric CPT codes representing the total obstetrical package.

Routine prenatal visits

Routine prenatal visits includedTypically 13 routine prenatal visits are included in the global obstetrical package (monthly through 28 weeks, then biweekly until 36 weeks and weekly until delivery)

Components included with visitsInitial and subsequent history and physical exams when pregnancy already established are part of the global package

Included monitoringCollection of weight, blood pressure, and fetal heart tones are included in routine prenatal visits

Related included servicesRoutine urinalysis and routine outpatient E&M services within 6 weeks of delivery are included

Maternity ultrasound reimbursement

Separate ultrasound reimbursement limitMaternity ultrasounds in excess of two per pregnancy/fetus are not eligible for separate reimbursement unless related to a problem-oriented diagnosis

Allowance per pregnancy/fetusUp to 2 maternity ultrasounds per pregnancy/fetus may be separately reimbursed when not problem-oriented

Documentation noteServices exceeding the limit must be related to a problem-oriented diagnosis to be separately reimbursed

Policy change contextReference to Maternity Ultrasound in the Outpatient Setting policy was removed (11/16/2022) as part of policy updates

Authorization, Documentation, and Billing Actions

Documentation Required

Authorization, documentation, and billing restrictions for global obstetrical codes

Providers must follow authorization and medical necessity guidelines and submit appropriate medical documentation when requested; Anthem reserves the right to request medical documentation for post‑pay review of paid claims. Global obstetrical codes are allowed only when all components (antepartum, delivery and postpartum) are provided by the same provider or provider group reporting under the same TIN; if not, bill only the elements actually provided. The Health Plan will not reimburse duplicate or overlapping services during the pregnancy and may recoup paid overlapping claims.

Global obstetrical codes allowed once per pregnancy period when billed by a single provider or provider group under the same federal TIN.
If all antepartum, delivery and postpartum services are not provided by the same TIN, global codes may not be used; submit only services provided.
Anthem reserves the right to request medical documentation to perform post‑pay review of paid claims.
The Health Plan will not reimburse duplicate or otherwise overlapping services during the course of the pregnancy.

Definitions and Package Components

Global obstetrical (total obstetrical) package

DefinitionThe total obstetrical package includes antepartum care, the delivery, and postpartum care (examples: CPT 59400 and 59510)

Examples of included delivery servicesVaginal or cesarean delivery of single gestation and delivery of the placenta are included in the global package

Postpartum inclusionRoutine outpatient E&M services within 6 weeks of delivery and postpartum care only are part of the global package

Procedures includedRepair of first- or second-degree lacerations and uncomplicated inpatient visits following delivery are included