CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Obstetrical global package billing and reimbursement

Guidelines for coding, documentation, and reimbursement of routine obstetrical care, multiple deliveries, nutritional counseling within the global period, and confirmation of pregnancy visits for providers billing Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyObstetrical global package billing and reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionBill a pregnancy-related diagnosis on the claim and use appropriate modifiers and supporting notes when seeking separate reimbursement within the global period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

global packagecomponents considered routine

up to global amountmax reimbursement if multiple vendors

reimbursedsame-day counseling policy

CMS-1500/UB-92claim form applicability

do not bill if already confirmedconfirmation visit billing rule

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Obstetrical Coverage and Billing Guidance

Obstetrical coverage criteria

Coverage determinations and billing guidance for services related to obstetrical care.

Routine obstetrical services are considered included in the global obstetrical package from the date the obstetrical medical record is established.

Included in global package

Initial and subsequent history
Physical examination
Recording of weight
Blood pressure checks
Monitoring of fetal heart tones
Routine chemical urinalysis
Routine visits
Management of uncomplicated labor and delivery services, including admission
Postpartum hospital and office visits following vaginal and cesarean delivery

Separate reimbursement for non-routine or unrelated visits

High-risk visits or visits for an unrelated diagnosis must be billed with supporting diagnosis codes for separate reimbursement to be considered
Appropriate modifiers should be used to indicate a separately identifiable service; notes may be required to support separate reimbursement

Nutritional counseling within the global period

Neighborhood will reimburse for nutritional counseling on the same day as an Evaluation and Management service rendered by the same provider
A pregnancy-related diagnosis must be billed on the claim when seeking reimbursement for counseling within the global period

Multiple deliveries coding

Both vaginal deliveries: bill 59400 for Twin A (first born) and 59409-51 for Twin B
Both cesarean deliveries: bill 59510 once with modifier -22
One vaginal and one cesarean: bill 59510 for the cesarean (primary procedure) and 59409-51 for the vaginal delivery
If more than two newborns are delivered, each additional baby is coded by type of delivery with the appropriate modifier

This guideline applies to both CMS-1500 and UB-92 claim submissions.

Confirmation of pregnancy visit

The confirmation of pregnancy visit is typically a minimal visit; the physician may draw blood and prescribe prenatal vitamins if results are positive
Do not bill a confirmation of pregnancy visit if pregnancy has already been confirmed by another physician or qualified health care professional (e.g., ultrasound, blood test)

If multiple vendors are reimbursed for routine care, Neighborhood will reimburse up to the total allowed global package amount.

Coding Examples for Multiple Deliveries

Multiple delivery coding examplesCPTCovered

59400	Vaginal delivery, first twin (Twin A)
59409-51	Vaginal delivery, second twin (modifier 51 for multiple procedures)
59510	Cesarean delivery (billed once for both twins with modifier -22 for increased procedural service)

Modifiers, Documentation, and Diagnosis Requirements

Documentation Required

Modifiers and documentation — use appropriate modifiers to indicate a separately identifiable service; notes may be required to support separate reimbursement.

Use appropriate CPT/HCPCS modifiers to indicate a separately identifiable service when billing services that occur during an obstetrical global period. Documentation (office notes, charting, and any supporting records) may be required to support separate reimbursement. When submitting a claim for a separately identifiable service, include clear documentation showing why the service is distinct from routine global obstetrical care (for example, treatment for an unrelated condition or an increased level of service beyond routine prenatal visits).

Use modifiers to denote separately identifiable services.
Provide contemporaneous documentation (notes/chart) to substantiate separate reimbursement.
If multiple vendors provide routine care, Neighborhood will reimburse up to the total allowed global package amount.

Routine Care and Confirmation Visit Definitions

inv-05: Routine obstetrical care

Initial and subsequent historyIncluded as part of routine obstetrical care within the global package.

Physical examinationIncluded as part of routine obstetrical care within the global package.

Recording of weight and blood pressure checksRoutine measurement of weight and blood pressure are included in the global obstetrical package.

Monitoring of fetal heart tonesRoutine fetal heart tone monitoring is included in the global obstetrical package.

Routine chemical urinalysis and routine visitsRoutine urinalysis and scheduled prenatal visits are included in the global obstetrical package.

Management of uncomplicated labor, delivery and postpartum visitsManagement of uncomplicated labor and delivery (including admission) and postpartum hospital and office visits following vaginal and cesarean delivery are included in the global obstetrical package.