CurrentHighmark Blueshield NenyPolicy RP-023

Urinary Incontinence Therapy and Global Maternity Care Billing and Reimbursement

Defines billing and reimbursement guidance for urinary incontinence therapy services (including biofeedback and related modalities) and global maternity care (antepartum, delivery, postpartum) for Highmark BlueShield NENY providers.

Policy Summary

PayerHighmark Blueshield Neny

PolicyUrinary Incontinence Therapy and Global Maternity Care Billing and Reimbursement

Policy CodePolicy RP-023

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInitial evaluation of urinary incontinence must be performed by a physician and billed with the appropriate E&M code; do not report E&M and therapy codes 97110 or 97530 on the same day by the same provider unless separately identifiable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99201-99205; 99241-99245; 99251-99255E&M codes referenced

90901, 90912, 90913Biofeedback codes

97110, 97530Therapy same-day restriction

Single-rateGlobal maternity rate

Antepartum+Delivery+Postpartum

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Global package includes

Coverage and Medical Necessity Criteria

Urinary incontinence therapy — coverage and billing rules

Covered when ALL of the following are met:

Urinary incontinence therapy consists of behavioral, exercise, and physical medicine techniques intended to enable voluntary control over urine discharge (initial evaluation and therapy).

ALL of the following

The initial evaluation of patients with urinary incontinence is performed by a physician.
The initial evaluation must be billed with the appropriate Evaluation and Management (E&M) code: 99201-99205 (new patient), 99241-99245 (office/outpatient consultant), or 99251-99255 (inpatient consultant).

ALL of the following

Biofeedback is reported using CPT codes 90901, 90912, or 90913 per AMA CPT guidance.
ONE of
- 90912 or 90913 include measurement of muscle movements by EMG (codes 57184, 57185) or manometry (91122).
- 90901 includes no measurement (coaching pelvic floor strengthening) and is bundled into 90912/90913 (no unbundling).

ALL of the following

Electrical stimulation of the pelvic floor may be reported with 97014 (unattended) or 97032 (attended, each 15 minutes).
Therapeutic ultrasound of the pelvic floor may be reported with 97035.

ALL of the following

E&M codes and occupational/therapy codes 97110 and 97530 are not to be reported on the same day by the same provider for therapy services unless there is documentation of a significant, separately identifiable service.

When 90901 is provided without measurement, it is considered bundled into 90912/90913 and should not be separately reported when 90912/90913 are billed.

Operational billing note

Global maternity care — criteria and components (antepartum, delivery, postpartum)

Global maternity care is covered as a single global package when ALL component requirements are met:

Highmark reimburses an uncomplicated maternity case at a single global contract rate when antepartum, delivery, and postpartum services are all provided by one provider or group.

ALL of the following

Physicians will be reimbursed separately for the first visit to confirm pregnancy; submit a claim at the time of the initial obstetric visit (include expected delivery date).
All subsequent office visits for maternity care, the delivery, and postpartum services are included in the global maternity care package and should be submitted after delivery and conclusion of postpartum services.

Global package includes antepartum care, delivery services, and postpartum care.

Antepartum care includes

Relevant Procedure and Service Codes

Urinary incontinence and related therapy codesCPTCovered

99201-99205	New patient E&M codes for initial evaluation of urinary incontinence
99241-99245	Office or outpatient consultant E&M codes
99251-99255	Inpatient consultant E&M codes
97110	Therapeutic exercise
97530	Therapeutic activities
90901	Biofeedback without measurement (coaching pelvic floor strengthening)
90912	Biofeedback with measurement (EMG or manometry)
90913	Biofeedback with measurement (EMG or manometry)
57184	EMG muscle measurement (referenced)
57185	EMG muscle measurement (referenced)

1–10 of 14

1/2

Global obstetric procedure codesCPTCovered

59610	Cesarean delivery (as referenced)
59612	Vaginal delivery after previous cesarean (as referenced)
59618	Attempted vaginal delivery after previous cesarean (as referenced)

Billing Rules and Provider Guidance

Billing Rule

Urinary incontinence initial evaluation and same-day billing

The initial evaluation of urinary incontinence must be performed by a physician and billed with the appropriate Evaluation and Management (E&M) code. E&M codes (e.g., 99201-99205 New Patient; 99241-99245 Office/Outpatient Consultants; 99251-99255 Inpatient Consultants) and occupational/physical therapy procedure codes (e.g., 97110, 97530) must not be reported on the same day by the same provider for therapy services unless the E&M service is documented as significant, separately identifiable from the therapy (supporting documentation required).

Applicable E&M codes: 99201-99205, 99241-99245, 99251-99255
Therapy codes often involved: 97110, 97530
Biofeedback CPTs: 90901 (no measurement), 90912, 90913 (include EMG 57184/57185 or manometry 91122)

Billing Rule

Global maternity billing and timing of claims

Highmark reimburses a single global rate for uncomplicated maternity care when antepartum, delivery, and postpartum services are provided by the same provider or group. Those services are included in the global package and are not to be reported separately. The initial visit to confirm pregnancy is reimbursable separately from the global maternity care and should be submitted at the time of that first obstetric visit; include the delivery date on claims. All subsequent maternity office visits, delivery, and postpartum services are part of the global maternity package and claims for the global period should be submitted after delivery and conclusion of postpartum services. This guidance applies to plans with maternity benefits.

Definitions and Code Clarifications

Biofeedback codes — definitions and mappings

Biofeedback CPT codes90901 (biofeedback without measurement), 90912 and 90913 (biofeedback with measurement)

Measurement methods referencedEMG measurement (codes 57184, 57185) or manometry (code 91122) are included with 90912/90913

Bundling rule90901 (coaching only, no measurement) is bundled into 90912/90913 and cannot be unbundled

Related pelvic floor modalitiesElectrical stimulation (97014 unattended; 97032 attended) and ultrasound (97035) may be performed along with biofeedback

Same-day reporting constraintE&M codes and occupational/therapy codes (e.g., 97110, 97530) should not be reported on the same day by the same provider for therapy services unless separately identifiable in documentation

Policy Summary

PayerHighmark Blueshield Neny

PolicyUrinary Incontinence Therapy and Global Maternity Care Billing and Reimbursement

Policy CodePolicy RP-023

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Prenatal history and examination and subsequent obstetrical visits.

Monthly visits to 28 weeks, biweekly visits to 36 weeks, weekly visits until delivery; obtaining history, recording weight, blood pressure, and fetal heart tones; routine chemical urinalysis.

Delivery services include

Admission to hospital and admission history and physical examination.
Management of uncomplicated labor and vaginal delivery (with or without episiotomy, with or without forceps) or cesarean delivery.

Postpartum care includes

Hospital visits and office visits following vaginal or cesarean delivery.

Services not included in the global package (examples): laboratory tests, amniocentesis, ultrasounds; excluded services will be billed separately with applicable cost sharing.

Refer to the global obstetric procedure codes (e.g., 59610, 59612, 59618) and to Highmark Reimbursement Policy RP-023 and the Provider Manual for appropriate coding guidance.

Coding

Global obstetric package includes antepartum, delivery, and postpartum care
Providers should submit a separate claim for the first visit to confirm pregnancy (submit at time of visit)
Include delivery date on claims; remaining maternity-related visits and delivery are billed as the single global package after delivery and postpartum are complete
Applies only to plans with maternity benefits

Global maternity care — single global rate and included services

What the global rate coversA single global contract rate covers antepartum care, delivery services, and postpartum care when all services are provided by one provider or group

ApplicabilityReimbursed for uncomplicated maternity cases in accordance with AMA CPT and ACOG guidance

Reporting requirementServices included in the global package (antepartum, delivery, postpartum) are not to be reported separately

First pregnancy-confirmation visitThe first visit to confirm pregnancy is reimbursed separately (per planner brief guidance) — subsequent routine antepartum visits are included in the global package

Covered obstetric procedure codesGlobal obstetric procedure codes referenced include cesarean and vaginal delivery codes (e.g., 59610, 59612, 59618 as listed in coding group)