CurrentBlue Cross Blue Shield - KansasPolicy N/A

Obstetrical (OB) Services — Content of Service and Billing Rules

Defines what is included in total obstetrical care (non‑surgical and surgical), billing rules for antepartum/delivery/postpartum care, related laboratory and anesthesia inclusions, and criteria for additional fees and individual consideration. Applies to providers billing Blue Cross Blue Shield of Kansas.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyObstetrical (OB) Services — Content of Service and Billing Rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing, include antepartum, delivery and postpartum as all‑inclusive when provided by the same physician; bill prior insurer or patient for services before BCBSKS effective date if member insured <240 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

240 dayscoverage lookback threshold

25%additional payment per extra child

antepartum, delivery, postpartumcomponents included

urinalysisroutine antepartum labs included

Coverage rules and billing criteria

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Coverage criteria and billing rules

Covered when the services fall within the usual fee for total obstetrical care; separate payment or individual consideration applies only as specified below:

Total OB care includes normal antepartum care, delivery (with or without low forceps and/or episiotomy), local anesthesia, and normal postpartum care.

Antepartum care includes office visits, routine urinalyses, fetal heart tone monitoring, nonstress testing, stress testing and internal fetal monitoring; these are part of total OB care unless medical necessity documentation supports otherwise.

Delivery includes the delivery and normal postpartum care; when the delivering physician also provides antepartum and postpartum care, bill as an all-inclusive charge under the appropriate code.

Postpartum care includes hospital care and office visits following delivery; if different physicians provide antepartum care and delivery, it is assumed the delivering physician provided post-delivery care unless correct obstetrical CPT codes indicate otherwise.

Usual-fee exclusions or items eligible for separate payment/individual consideration

Laboratory tests are not included in the usual antepartum fee except for routine urinalyses; specific prenatal tests for complicated or unusual problems may be allowed only by individual consideration with documentation of medical necessity.
Local anesthesia is included in the delivery charge; see anesthesia policy for other anesthesia-related matters.
In-hospital treatment of severe antepartum or postpartum complications may be eligible for additional in-hospital medical care fees subject to medical necessity review and supporting records.
Non-stress testing and internal fetal monitoring are part of the regular attending provider's content of service unless unusual, medically necessary conditions require review and concurrence; stress testing requires substantiation of medical necessity and concurrence of review.
When outpatient emergency/observation obstetrical care is provided by a physician other than the patient's regular attending obstetrician, the service may be eligible for a separate fee; care by the regular attending is within the usual fee.

If a patient has been insured by BCBSKS for less than 240 days, bill services provided after the BCBSKS effective date to BCBSKS and bill prior services to the previous insurer or the patient as appropriate.

Additional fees requiring review or special handling

Higher than usual professional charges for unusual complications, including threatened miscarriage or other atypical events, require consultant review and substantiation of medical necessity; approval is subject to the consultant's concurrence.
When multiple births occur, an additional 25% of the maximum allowable payment for the delivery performed will be allowed for each additional child.
Dilation and curettage (D&C) for miscarriage, postpartum bleeding, or therapeutic abortion are governed by surgical policy and/or individual consideration per surgical policy; if only medical care is involved, in-hospital medical care policy governs.

Obstetrical service components and coding notes

Obstetrical global service componentsmixed

No codes listed

New member coverage lookback

Lookback thresholdIf member has been insured by BCBSKS for less than 240 days, bill services after BCBSKS effective date to BCBSKS; services before the BCBSKS effective date are the responsibility of the previous insurer or the patient.

When to bill prior insurerUse appropriate codes to bill services provided before the BCBSKS effective date to the previous insurance carrier (or to the patient if no prior coverage).

Services after BCBSKS effective dateBill services provided after the BCBSKS effective date to BCBSKS using appropriate obstetrical codes.

Review, documentation, and special fee considerations

Prior Authorization

Consultant review required for unusual/extra fees; multiple-birth and emergency-care fee rules

Higher-than-usual professional charges and unusual full-term fees require consultant review and must be substantiated as medically necessary; the consultant's determination is binding on the contracting provider. For multiple births, add 25% of the maximum allowable payment for each additional child. Separate payment for emergency/observation obstetrical care may be allowed when provided by a physician other than the patient’s regular attending obstetrician.

Higher-than-usual professional charges and unusual complications are subject to consultant review and require documentation supporting medical necessity; approval depends on the consultant’s concurrence (chunk 6).
When multiple births occur, an additional 25% of the maximum allowable payment for the delivery will be allowed for each additional child (chunk 6).
Outpatient emergency or observation obstetrical care provided by a physician other than the regular attending obstetrician is eligible for a separate fee; care by the regular attending is considered within the usual fee (chunk 7).

Definitions of total OB care and surgical delivery care

Total OB care (definition)

Definition of Total OB careTotal OB care includes normal antepartum care, delivery (with or without low forceps and/or episiotomy), local anesthesia, and normal postpartum care.

Antepartum components includedAntepartum care includes office visits, routine urinalyses, fetal heart tone monitoring, nonstress testing, stress testing and internal fetal monitoring.

Postpartum care includedPostpartum care includes hospital care and office visits following delivery; when same physician provides antepartum, delivery and postpartum, bill as an all-inclusive charge under the appropriate code.

Surgical Delivery Care (definition)

Definition of Surgical Delivery CareSurgical Delivery Care includes preoperative care from admission to the time of surgical delivery, the surgical delivery itself, and postoperative/postpartum care through the period of usual hospitalization ending with the final postpartum examination.

Billing when surgeon also provides ante/postpartum careIf the delivering physician also provides antepartum and postpartum care in addition to surgical delivery, total OB care is billed as an all-inclusive charge under the appropriate code.

Multiple-physician scenariosWhen different physicians provide antepartum care and surgical delivery, it is assumed the delivery physician provided post-delivery care; if not, indicate this using the correct obstetrical CPT code(s).