CurrentOscar HealthPolicy N/A

Obstetrical Care Bundling

Defines reimbursement and billing rules for global obstetrical (OB) package codes, itemization of maternity services, and when components (antepartum, delivery, postpartum) may be billed separately for Oscar Health members in NC.

Policy Summary

PayerOscar Health

PolicyObstetrical Care Bundling

Policy CodePolicy N/A

Change TypeMaterial updates to assistant surgeon and multiple gestation guidance

Effective DateJul 1, 2025

Next Review DateMay 5, 2025

Key ActionBill the global OB package only when antepartum, delivery, and postpartum care are all provided by the Same Group under the same TIN; otherwise itemize applicable components.

SourceLink

POLICY UPDATE CHANGES

Reorganized content so the Global Obstetrical Care Package, Services Excluded from the Global Package, and Services Included in the Delivery Services Only package are sub-headings and replaced tables with bullet points.

Added additional codes to the Multiple Gestation section for completeness.

Added new sub-headings and reimbursement guidelines for Assistant Surgeon for Cesarean Sections and Itemization of OB Services.

4primary global OB CPT codes referenced

~13routine antepartum visits (typical)

6 weekspostpartum period included

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Coverage and Reimbursement Criteria

Reimbursement criteria for global OB and itemized services

Oscar reimburses global OB codes when all package components (antepartum, delivery, postpartum) are provided by the Same Group under the same TIN; certain services are excluded from the global package and may be billed separately under specified conditions.

Global OB package reimbursed when all components (antepartum care, delivery, and postpartum care) are provided by the Same Group Physician and/or Other Health Care Professional under the same TIN.

Examples of primary global OB CPT codes include 59400, 59510, 59610, 59618.

ALL of the following

Included services: all routine prenatal visits (approximately 13 for uncomplicated cases); recording of weight, blood pressures and fetal heart tones; initial and subsequent history and physical exams; routine chemical urinalysis; admission to hospital including history and physical; inpatient E/M service provided within 24 hours of delivery; management of uncomplicated labor; delivery of placenta; administration/induction of IV oxytocin; insertion of cervical dilator on same date as delivery; repair of first or second degree lacerations; simple removal of cerclage (not under anesthesia); uncomplicated inpatient visits following delivery; routine outpatient E/M services within 6 weeks of delivery.

Services excluded from the global package (may be reported separately)

Initial E/M to diagnose pregnancy if antepartum record is not initiated at the confirmatory visit (support with diagnosis code Z32.01).
Laboratory tests (excluding routine chemical urinalysis).
Maternal or fetal echography (obstetric ultrasound) procedures.
Amniocentesis (any method) and chorionic villus sampling (CVS).
Amnioinfusion, fetal contraction stress test, fetal non-stress test, external cephalic version.
Insertion of cervical dilator more than 24 hours before delivery.

Separate E/M visits for high-risk or complications

Additional E/M visits beyond the typical 13 antepartum visits for high risk or complications may be reported in addition to the global code; these visits should be submitted at time of delivery to allow assessment of total antepartum visits.
Append modifier 25 to E/M services to identify them as significant and separate from routine antepartum care; when an E/M and an OB ultrasound are performed same day by the same individual, modifier 25 must be appended to the E/M to bill separately.

Assistant surgeon for cesarean: Assistant surgeon services for cesarean delivery are reimbursable only when billed with non-global cesarean delivery codes (e.g., 59514 or 59620) and an appropriate assistant surgeon modifier; global obstetric codes are not payable for assistant surgeon services.

When itemization of OB services is permitted

Patient transfers into or out of a physician or group practice.
Patient is referred to another physician during pregnancy.
Patient terminates or miscarries her pregnancy.
Delivery performed by a physician or other qualified health care professional not associated with the patient's physician or group practice.
Patient changes insurers during her pregnancy.

Coverage stance: global OB codes are covered when criteria are met; select services are separately reimbursable when conditions and modifier requirements (e.g., modifier 25, appropriate assistant surgeon modifier) are satisfied.

Obstetrical Codes and Visit Counts

Obstetrical package and component CPT codesCPTCovered

59400	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care.
59510	Routine obstetric care including antepartum care, cesarean delivery and postpartum care.
59610	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery.
59618	Routine obstetric care including antepartum care, cesarean delivery; and postpartum care, following attempted vaginal delivery after previous cesarean delivery.
59425	Antepartum care only; 4-6 visits.
59426	Antepartum care only; 7 or more visits.
59409	Vaginal delivery only (with or without episiotomy and/or forceps).
59514	Cesarean delivery only.
59612	Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps).
59620	Cesarean delivery only; following attempted vaginal delivery after previous cesarean delivery.

1–10 of 15

1/2

Routine antepartum visit count — inv-03

Typical antepartum visit countApproximately 13 visits for uncomplicated pregnancies

High‑risk or complication visitsAdditional visits beyond 13 may be separately reported when related to complications; submit at time of delivery with modifier 25 and appropriate diagnosis

What is included in routine antepartum visitsRecording of weight, blood pressures, fetal heart tones, initial/subsequent H&P, routine chemical urinalysis

Billing Actions, Modifiers, and Assistant Surgeon Rules

Billing Rule

When to bill global vs itemize

Bill the global maternity package only when the same group (same TIN) provides all components: antepartum (prenatal) care, delivery (labor and delivery), and postpartum care. If any component is furnished by a different group or the patient transfers, is referred, miscarries/terminates pregnancy, or changes insurers, itemize services instead of billing the global code.

Global package requires Same Group Physician/Other Health Care Professional reporting under the same TIN
Itemize when patient transfers into/out of a practice, is referred, terminates or miscarries, has delivery by a different provider/group, or changes insurers

Billing Rule

Modifier 25 for separate E/M

Append modifier 25 to an E/M service when it is a distinct, separately identifiable visit related to high-risk or complicated pregnancy care performed on the same day as routine antepartum services or OB ultrasound. Oscar follows ACOG and CPT guidance: modifier 25 must be present to qualify for separate reimbursement.

Definitions

Global Obstetrical Care — inv-07

DefinitionThe total obstetric package including provision of antepartum care, delivery, and postpartum care; when the Same Group provides all components, report the global OB package code (e.g., CPT 59400, 59510, 59610, 59618)

Typical components includedAll routine prenatal visits until delivery (~13 for uncomplicated cases), hospital admission/H&P, inpatient E/M within 24 hours of delivery, management of uncomplicated labor, delivery of placenta, routine postpartum visits up to 6 weeks

Routine procedures includedRecording weight/BP/fetal heart tones, routine chemical urinalysis, induction/administration of IV oxytocin, repair of 1st–2nd degree lacerations, simple cerclage removal (not under anesthesia)

Same Group Physician and/or Other Health Care Professional — inv-08

Same Group — definitionPhysicians and/or other healthcare professionals of the same group reporting the same Federal Tax Identification Number (TIN)