CurrentBlue Cross Blue Shield - MainePolicy G-14001

Maternity Services, Reimbursement Policy

This policy governs reimbursement for global obstetrical (maternity) services for Anthem Medicare Advantage members in specified states, explaining billing, allowed separate services, and when claims may be denied or recouped. It affects providers and facilities billing obstetric care under the same TIN.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMaternity Services, Reimbursement Policy

Policy CodePolicy G-14001

Change TypeNo material change

Effective Date07/07/2023

Next Review DateN/A

Key ActionProvide appropriate documentation upon request for post-pay review and follow coding/billing guidelines to avoid denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

279 dayspregnancy period used for global code

13 visitstypical prenatal visits included

07/07/2023effective date

G-14001policy id

Maternity Coverage Criteria

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Maternity coverage criteria

Covered with criteria — reimbursement rules for global obstetrical services and separately billable elements.

Global obstetrical codes are allowed once per pregnancy period (defined as 279 days) when appropriately billed by a single provider or provider group reporting under the same federal Tax Identification Number (TIN). Reimbursement is based on the provider/group providing all aspects of the global obstetric care package (antepartum, delivery, and postpartum). If the provider/group does not provide all elements, global codes may not be used and only the elements actually provided should be submitted for reimbursement.

Anthem will not reimburse duplicate or otherwise overlapping services during the course of the same pregnancy; payment of global, delivery only, delivery/postpartum, antepartum only, or postpartum only services for the same pregnancy may result in denial of additional claims or recoupment of previously paid overlapping claims.

If prior services paid for same pregnancy

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 for cesarean deliveries may be reimbursed separately when the appropriate modifier is appended.
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 recoupment of previously paid overlapping services.
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.

Elements included in the global package (not separately reimbursable)

Initial and subsequent history and physical exams after pregnancy diagnosis is established.
All routine prenatal visits until delivery (typically 13 visits: monthly through 28 weeks, biweekly until 36 weeks, then weekly until delivery).
Additional visits for high-risk history or potential problems that 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; insertion of cervical dilators on the same date of delivery; simple removal of cerclage.

Elements 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 in excess of 13 for an active high-risk complication — these additional visits must be submitted for payment 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 if clearly not related to pregnancy.
Maternal or fetal echocardiography, amniocentesis, chorionic villus sampling, fetal contraction stress/nonstress testing, biophysical profile, amnioinfusion.

Coding and documentation requirements

Providers must use the appropriate diagnosis code on professional delivery service claims to indicate outcome of delivery; diagnosis codes indicating gestational weeks are required on all professional delivery service claims and recommended for other pregnancy-related claims. Failure to report the appropriate diagnosis code will result in denial of the claim.
Providers should use appropriate E/M codes for antepartum and postpartum care and follow standard correct coding practices. Anthem reserves the right to request medical documentation to perform post-pay review of paid claims.

Modifiers, Codes, and Visit Counts

Modifiers and coding notesModifier

Modifiers 59, XE, XP, XS, XU	Distinct Procedural Services modifiers referenced in Definitions
Modifier 25	Required for additional antepartum E/M visits billed at delivery for active high-risk complications

Routine prenatal visits included

Typical number of routine prenatal visits includedTypically 13 visits (monthly through 28 weeks, then biweekly until 36 weeks and weekly until delivery)

Routine prenatal visits are part of global packageAll routine prenatal visits until delivery are not separately reimbursable when a global obstetrical CPT code is billed

Related routine services includedIncludes collection of weight, blood pressure, and fetal heart tones and routine urinalysis

Documentation, Review, and Billing Compliance

Documentation Required

Documentation and Post‑Payment Review Rights

Anthem Medicare Advantage may request medical records and supporting documentation to perform post-payment review of paid claims. Providers must retain and produce medical records, office notes, and any other documentation that substantiates the services billed upon request.

Maintain complete, legible medical records for all services billed.
Provide documentation promptly when requested for post-payment review.
Ensure records support the level of service, codes, and dates billed.

Billing Rule

Billing and Coding Compliance — Potential Denial and Recovery

Failure to follow coding, billing, and submission guidelines — including use of accurate CPT, HCPCS, and revenue codes — may result in administrative actions. Anthem Medicare Advantage may reject or deny claims, recover or recoup payments, or adjust reimbursement when documentation or coding does not support billed services.

Use industry-standard CPT, HCPCS, and revenue codes that accurately describe the services performed.
Ensure billed services are fully supported in the medical record and office notes.
Be aware that noncompliance may trigger claim rejection, denial, recoupment, or adjusted reimbursement.

Claims Requiring Additional Documentation

Claims Requiring Additional Documentation — Distinct Procedural Services

DefinitionClaims Requiring Additional Documentation = Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)

PurposeThese modifiers identify services that may need additional documentation to support that procedures were distinct or separate from other billed services

When appliedUsed when billing procedures that could be considered part of a global service to indicate distinct procedural services

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMaternity Services, Reimbursement Policy

Policy CodePolicy G-14001

Change TypeNo material change

Effective Date07/07/2023

Next Review DateN/A

Key ActionProvide appropriate documentation upon request for post-pay review and follow coding/billing guidelines to avoid denial or recoupment.

SourceLink

On This Page

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 six weeks of delivery.

Discussion of contraception; postpartum care only; education on breastfeeding, lactation, exercise, or nutrition.

Insertion of cervical dilator occurring more than 24 hours prior to delivery; inpatient E/M encounters occurring more than 24 hours prior to delivery; management of surgical problems arising during pregnancy; care by maternal fetal medicine specialists.

Ultrasound (refer to Maternity Ultrasound policy) and external cephalic version.