CurrentBlue Cross Blue Shield - MainePolicy C-19004

Maternity Services (global obstetric reimbursement)

Defines reimbursement rules for global obstetrical codes and component maternity services (antepartum, delivery, postpartum) for commercial professional providers submitting under the same TIN.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMaternity Services (global obstetric reimbursement)

Policy CodePolicy C-19004

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionMay request medical documentation for post-pay review; services must meet authorization and medical necessity guidelines and member state rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

once per pregnancyGlobal obstetrical codes reimbursed

~13Routine prenatal visits included

90-dayPostpartum period (59430)

multipleSeparately billable services

Coverage and Reimbursement Rules

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Global obstetrical codes allowed once per pregnancy when billed by a single provider or provider group under the same TIN.

Reimbursement is based on all aspects of the global obstetric care package (antepartum, delivery, postpartum) being provided by the provider or provider group reporting under the same TIN; if not all components are provided, global codes may not be used and only the elements actually provided should be submitted.

The health plan will not reimburse for duplicate or otherwise overlapping services during the course of the pregnancy.

Billing conflict outcomes

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 overlapping claim to be recouped.
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 surgeon payment for cesarean delivery may be separately reimbursed when the appropriate modifier is appended.
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 recoupment of previously paid overlapping services.
If Global or Antepartum Only services have been paid during the same pregnancy, a claim for Antepartum Only services may be denied.
Postpartum Only claims may be denied if Global, Delivery/Postpartum, or Postpartum Only services have already been paid during the same pregnancy.

Providers should use appropriate E/M codes for antepartum and postpartum care; the plan reserves the right to request documentation for post-pay review to support medical necessity and correct billing.

Inclusions and exclusions

Specific inclusions and exclusions for the global package.

Included in Global Package: Initial and subsequent history and physical exams when pregnancy diagnosis has already been established; all routine prenatal visits until delivery (typically monthly through 28 weeks, then biweekly until 36 weeks and weekly until delivery — usually about 13 visits); routine collection of weight, blood pressure and fetal heart tones; routine urinalysis; hospital admission including history and physical; inpatient E/M services within 24 hours of delivery; management of uncomplicated labor (including administration of labor inducing agents), insertion of cervical dilators on same date of delivery, simple removal of cerclage; vaginal (including forceps or vacuum assisted) or cesarean delivery of single gestation and delivery of the 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; and augmentation of labor, amniotomy, and vacuum extraction (these are included in the global reimbursement and not separately reimbursable).

Not Included / Separately Billable: 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 an active high-risk complication (these additional visits must be submitted at 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 if clearly unrelated); maternal or fetal echocardiography; amniocentesis; chorionic villus sampling; fetal contraction stress testing and nonstress testing; biophysical profile; amnioinfusion; insertion of cervical dilator occurring more than 24 hours before delivery; inpatient E/M encounters occurring more than 24 hours before delivery; management of surgical problems arising during pregnancy; care provided by maternal-fetal medicine specialists; ultrasound; and external cephalic version.

Billing requirement for additional antepartum visits: Additional antepartum E/M visits (>13) for an active high-risk complication must be submitted with Modifier 25 and an appropriate high-risk diagnosis and billed at the time of delivery.

Representative Codes and Visit Expectations

Representative CPT codesCPTCovered

59400 / 59510	Global obstetric care package examples (antepartum, delivery, postpartum)
59430	Postpartum care only (90-day postpartum period applies)

Routine prenatal visits included

Routine prenatal visits (typical count)Approximately 13 visits

Timing of visitsMonthly through 28 weeks, biweekly until 36 weeks, then weekly until delivery

Elements included in routine visitsCollection of weight, blood pressure, and fetal heart tones; routine urinalysis

Scope relative to high-riskAdditional visits for high‑risk pregnancy that do not develop or are inactive in current pregnancy are included

Relation to global billingAll routine prenatal visits are not separately reimbursable when any CPT code for global services is billed

Documentation, Medical Necessity, and Billing Responsibilities

Documentation Required

Provide documentation and meet medical necessity for antepartum/postpartum services

May request medical documentation for post‑pay review; services must meet authorization and medical necessity guidelines and member state of residence rules. Providers should use appropriate E/M codes for antepartum and postpartum care and ensure all billed services are fully supported in the medical record; failure to follow coding/billing or documentation requirements may result in claim denial or recoupment.

Requests for medical documentation may be made to perform post‑pay review of paid claims.
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence.
All services must be billed with compliant CPT/HCPCS/revenue codes and fully supported in the medical record.
Noncompliance with coding/billing guidelines can lead to claim rejection, denial, or recovery/recoupment of payment.

Key Definitions

Global Obstetric Care Package

DefinitionThe global obstetric care package includes antepartum care, the delivery, and postpartum care (e.g., CPT codes 59400 and 59510)

Components includedAntepartum care, delivery (vaginal or cesarean of single gestation), delivery of placenta, and postpartum care

Typical services bundledInitial and subsequent H&P after pregnancy diagnosis, management of uncomplicated labor, routine postpartum visits within 6 weeks, education (breastfeeding, lactation, nutrition)

Routine procedures includedAugmentation of labor, amniotomy, vacuum extraction, insertion of cervical dilators on same date of delivery, simple cerclage removal