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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint Maternity Reimbursement Update | OpenPay…
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    CurrentWellpointPolicy G-14001

    Maternity Services

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    This policy governs Wellpoint Washington Medicaid reimbursement and claim-reporting requirements for antepartum care, labor management, delivery, and postpartum care.

    Policy Summary
    PayerWellpoint
    PolicyMaternity Services
    Policy CodePolicy G-14001
    Change TypeMaterial policy update
    Effective DateJanuary 1, 2027
    Last ReviewSep 9, 2026
    Next Review DateNot specified
    Key ActionReport each antepartum E/M encounter with the applicable E/M code and modifier TH, including a Z3A diagnosis on the first prenatal visit after pregnancy confirmation.
    SourceLink
    POLICY UPDATE CHANGES

    The policy replaced the global obstetric care package approach with service-level reimbursement guidance for maternity care.

    The policy was updated to align with AMA CPT coding changes for maternity care services.

    A related maternity services CPT code list was added to the policy materials.

    Multiple maternity-specific definitions were added.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    13
    Routine antepartum visits
    3Routine postpartum visits
    16Combined maternity visits
    1Labor management services per day and setting
    12 weeksPostpartum limit period

    Maternity Service Reimbursement

    Maternity service reimbursement criteria

    Maternity services are reimbursable when appropriately reported and supported by documentation, subject to applicable service-specific requirements and routine visit limits.

    Maternity service is appropriately reported and supported

    • The service is antepartum care, labor management, delivery, or postpartum care.
    • Medical record documentation supports the reported code, date of service, place of service, maternity care phase, E/M level or labor management complexity, required modifiers, diagnoses, and separately reported services.
    • Applicable service-specific CPT, modifier, and gestational-age diagnosis requirements are met.

    Routine pregnancy frequency limits apply

    • Routine antepartum office or other outpatient E/M services do not exceed 13 visits per pregnancy episode under the same federal TIN.
    • Routine postpartum office or other outpatient E/M services do not exceed 3 visits per pregnancy episode within 12 weeks after delivery under the same TIN.
    • Combined routine antepartum and outpatient postpartum E/M services do not exceed 16 visits per pregnancy episode under the same TIN.

    Frequency-limit exception or separately reimbursable service applies

    • Diagnosis coding identifies a high-risk pregnancy or active pregnancy-related complication for antepartum E/M services exceeding the routine 13-visit limit.
    • Diagnosis coding identifies a pregnancy-related or postpartum complication for postpartum E/M services exceeding the routine 3-visit limit.
    • The service is separately reimbursable, such as a qualifying additional E/M service, qualifying laceration repair, hysterectomy performed during the same operative session as cesarean delivery, or uterine tamponade when the procedure is performed.

    Services included or not separately reimbursable

    The following services are included in applicable maternity reimbursement or are otherwise not separately reimbursable when the stated conditions apply.

    Service is included or not separately reimbursable

    • Routine antepartum office or other outpatient E/M services exceed 13 visits per pregnancy episode under the same TIN.
    • A listed service is reported on the same calendar date as the applicable antepartum office or other outpatient E/M service, with an applicable maternity diagnosis and under the same TIN. Listed services include routine urinalysis or point-of-care urine testing (81000, 81001, 81002, 81003, 81015); urine pregnancy testing (81025); preventive counseling (99401-99404); self-management education (98960-98962); prenatal and lactation education (S9443, S9445); behavioral screening (96127); depression screening (G0444); health-risk assessments (96160, 96161); prolonged E/M services (99417, G2212); remote physiologic monitoring setup and device supply (99453, 99454); and tobacco cessation services (99406, 99407).
    • More than one labor management service is reported for the same calendar date and setting; when more than one level is reported, reimbursement is limited to the highest applicable level.

    Coding and Reimbursement Limits

    Maternity modifiers and gestational-age diagnosismixedCovered
    THObstetrical treatment or services, prenatal or postpartum; required on antepartum and postpartum E/M services.
    Z3A categoryICD-10-CM codes identifying completed weeks of gestation; required for the first prenatal E/M visit after pregnancy confirmation and professional delivery claims, but not required on postpartum E/M claims.
    Labor managementCPTCovered
    59080-59083CPT labor management codes.
    DeliveryCPTCovered
    59431Applicable delivery code.
    59432Applicable delivery code.
    59502Applicable delivery code.
    59503Applicable delivery code.
    Separately reimbursable maternity proceduresCPTCovered
    59300Repair of a first- or second-degree episiotomy or laceration; separately reimbursable when performed by a professional other than the professional reporting the vaginal delivery.
    59414Delivery of the placenta; separately reimbursable when performed by a professional other than the professional reporting the vaginal delivery.
    59433Repair of a third- or fourth-degree episiotomy or laceration when performed at vaginal delivery.
    59434Repair of a third- or fourth-degree episiotomy or laceration when performed at vaginal delivery.
    59504Subtotal or total hysterectomy performed during the same operative session as cesarean delivery; modifier 51 is required when the same physician reports both procedures.
    59623Uterine tamponade when the procedure is performed; separately reimbursable.
    Services included in antepartum E/M reimbursementmixedNot Covered
    81000, 81001, 81002, 81003, 81015Routine urinalysis and point-of-care urine testing; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    81025Urine pregnancy testing; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    99401-99404Preventive counseling; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    98960-98962Self-management education; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    S9443, S9445Prenatal and lactation education; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    96127Behavioral screening; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    G0444Depression screening; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    96160, 96161Health-risk assessments; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    99417, G2212Prolonged E/M services; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    99453, 99454Remote physiologic monitoring setup and device supply; included in applicable antepartum E/M reimbursement when reported under the specified conditions.
    1–10 of 11
    1/2
    Routine antepartum E/M limit
    Maximum visitsUp to 13 routine office or other outpatient E/M visits per pregnancy episode.
    TIN requirementServices must be reported under the same federal tax identification number (TIN).
    Included visitThe first prenatal E/M visit following confirmation of pregnancy is included in the 13-visit limit.
    Routine outpatient postpartum E/M limit
    Maximum visitsUp to 3 routine office or other outpatient E/M visits per pregnancy episode.
    Post-delivery period

    Claim Reporting and Documentation Requirements

    Billing Rule

    Report Antepartum Care Per Encounter

    Report each antepartum encounter with the applicable E/M code and modifier TH. The first prenatal E/M visit after pregnancy confirmation is included in the routine visit limit and must include an applicable ICD-10-CM Z3A code identifying completed weeks of gestation as a condition of reimbursement.

    • Up to 13 routine office or other outpatient E/M visits are reimbursable per pregnancy episode for services reported under the same federal tax identification number (TIN).
    • Transfers to a provider or provider group reporting under a different TIN apply the routine antepartum limit separately to the receiving TIN.
    • A transfer between physicians or other qualified healthcare professionals reporting under the same TIN does not start a new frequency limit.
    Billing Rule

    Report Postpartum Care Per Encounter

    Report each postpartum encounter with the applicable E/M code and modifier TH. Postpartum routine E/M visits are reimbursable within 12 weeks after delivery, subject to the pregnancy-episode and TIN limits; an ICD-10-CM Z3A code is not required on postpartum E/M claims.

    Maternity Care Terms

    Antepartum care
    DefinitionManagement of the pregnancy before the onset of labor.
    ReportingReported per encounter with the applicable E/M code.
    Care phaseAntepartum care occurs before labor begins.
    Delivery
    DefinitionManagement of the parturient and fetus(es) beginning when labor is complete or interrupted and continuing through vaginal or cesarean delivery.
    Included careImmediate postpartum care on the delivery date is included.
    Delivery period
    Policy Summary
    PayerWellpoint
    PolicyMaternity Services
    Policy CodePolicy G-14001
    Change TypeMaterial policy update
    Effective DateJanuary 1, 2027
    Last ReviewSep 9, 2026
    Next Review DateNot specified
    Key ActionReport each antepartum E/M encounter with the applicable E/M code and modifier TH, including a Z3A diagnosis on the first prenatal visit after pregnancy confirmation.
    SourceLink
    On This Page
    Maternity Service ReimbursementCoding and Reimbursement LimitsClaim Reporting and Documentation RequirementsMaternity Care Terms
    Interim physical examinations, collection and interpretation of physiologic data, maternal and fetal monitoring, or labor induction or augmentation are performed as part of labor management.
  1. Labor management is reported for a scheduled or planned cesarean delivery when the patient is not in labor.
  2. Immediate postpartum care is rendered on the same calendar date as delivery.
  3. Hospital inpatient or observation discharge day management is reported when the patient is discharged on the same calendar date as delivery.
  4. Delivery of the placenta or repair of a first- or second-degree episiotomy or laceration is performed by the same physician or other qualified healthcare professional reporting the vaginal delivery.
  5. Initial or subsequent hospital inpatient or observation E/M services are reported on the same calendar date as a repeat cesarean delivery.
  6. Routine postpartum office or other outpatient E/M services exceed 3 visits per pregnancy episode within 12 weeks after delivery under the same TIN.
  7. Uterine tamponade is reported when only pharmacologic management of hemorrhage is provided.
  8. Maternity care services are duplicate or otherwise overlapping.
    9. Visits must occur within 12 weeks after delivery.
    TIN requirementServices must be reported under the same TIN.
    Combined routine maternity E/M limit
    Combined limitThe combined routine antepartum and outpatient postpartum limit is 16 visits per pregnancy episode.
    Services includedThe limit combines routine antepartum and outpatient postpartum E/M visits.
    ApplicationThe limit applies to services reported under the same federal TIN.
    Labor management frequency limit
    FrequencyReimbursement is limited to one labor management service per calendar date and per setting.
    Multiple levelsWhen more than one level is reported, reimbursement is limited to the highest applicable level.
    Reporting codesLabor management must be reported with CPT codes 59080-59083.
    • Up to three routine office or other outpatient E/M visits are allowed per pregnancy episode for services reported under the same TIN.
    • The combined routine antepartum and outpatient postpartum limit is 16 visits per pregnancy episode for services reported under the same TIN.
    • Postpartum care must be reported per encounter.
    Billing Rule

    Report Labor Management

    Report labor management using the applicable CPT code from 59080 through 59083. Reimbursement is limited to one labor management service per calendar date, per setting, at the highest applicable level.

    • Applicable codes: CPT 59080, 59081, 59082, and 59083.
    • Apply the one-service-per-calendar-date, per-setting frequency limitation.
    Billing Rule

    Report Delivery Services

    Report delivery using the applicable delivery CPT code and include an applicable ICD-10-CM Z3A code identifying completed weeks of gestation at delivery on all professional delivery claims as a condition of reimbursement.

    • Applicable delivery CPT codes: 59431, 59432, 59502, and 59503.
    • Select the delivery code that applies to the service performed.
    • Report completed weeks of gestation at delivery with the applicable Z3A code.
    Documentation Required

    Support Claims With Documentation

    Maintain medical-record and office-note support for every claim and for any exception to routine frequency limits. The health plan may request records and conduct prepayment or post-payment review; unsupported or noncompliant claims may be rejected, denied, recouped, or adjusted.

    • Document the reported code, date of service, place of service, maternity care phase, and E/M level or labor-management complexity.
    • Support the required modifier, any diagnosis used to support an exception to routine frequency limits, and each separately reported procedure or service.
    • Ensure CPT, HCPCS, revenue, and diagnosis coding is accurate, compliant, and fully supported by the medical record and/or office notes.
    • Claims must also meet applicable authorization and medical-necessity requirements.
    Billing Rule

    Apply Pregnancy Episode and TIN Limits

    Apply routine visit limits by pregnancy episode and federal TIN. A provider transfer to a different TIN starts a separate antepartum limit for services furnished under the receiving TIN, while transfers within the same TIN do not; the combined antepartum and outpatient postpartum limit remains 16 visits per pregnancy episode under the same TIN.

    • Antepartum limit: up to 13 routine office or other outpatient E/M visits per pregnancy episode per TIN.
    • Postpartum limit: up to three routine office or other outpatient E/M visits within 12 weeks after delivery per pregnancy episode per TIN.
    • A different TIN receives a separately applied routine antepartum frequency limit.
    • Transfers between physicians or other qualified healthcare professionals under the same TIN do not initiate a new frequency limit.
    The delivery management period continues through vaginal or cesarean delivery.
    High-risk pregnancy
    DefinitionA pregnancy with a documented maternal, fetal, or obstetric condition, complication, or risk factor requiring surveillance, evaluation, or management beyond routine maternity care.
    Qualifying conditionsThe condition, complication, or risk factor may be maternal, fetal, or obstetric.
    DocumentationThe condition, complication, or risk factor must be documented.
    Labor management
    DefinitionIntegrated decision-making and management of the parturient and fetus(es).
    SettingThe parturient is admitted to a facility for labor management or induction.
    Care scopeLabor management addresses both the parturient and fetus(es).
    Modifier 25
    DefinitionA significant, separately identifiable E/M service performed by the same physician or other qualified healthcare professional on the same date as another procedure or service.
    ProviderThe service is performed by the same physician or other qualified healthcare professional.
    TimingThe E/M service occurs on the same date as another procedure or service.
    Modifier TH
    DefinitionObstetrical treatment or services, prenatal or postpartum.
    Required useModifier TH is required on antepartum and postpartum E/M services under this policy.
    Care phasesThe modifier applies to prenatal and postpartum services.
    Postpartum care
    DefinitionOngoing assessment and management of the patient after delivery.
    ReportingReported per encounter with the applicable E/M code.
    Care phasePostpartum care occurs after delivery.
    Pregnancy episode
    DefinitionThe period beginning with the first pregnancy-related maternity service and ending 12 weeks after delivery.
    PurposeThe pregnancy episode is used to apply the routine antepartum and outpatient postpartum E/M visit limits.
    Visit limitsThe 13-visit antepartum limit, 3-visit outpatient postpartum limit, and combined 16-visit limit apply per pregnancy episode to services reported under the same federal TIN.
    Routine pregnancy
    DefinitionA pregnancy without a documented maternal, fetal, or obstetric condition, complication, or risk factor requiring surveillance, evaluation, or management beyond routine maternity care.
    Documentation standardNo qualifying maternal, fetal, or obstetric condition, complication, or risk factor is documented.
    Distinguishing featureThe pregnancy does not require management beyond routine maternity care.