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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint Maternity Services Policy Update | OpenP…
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    ModifiedWellpointPolicy G-14001

    Maternity Services

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

    Policy Summary
    PayerWellpoint Maryland Medicaid
    PolicyMaternity Services
    Policy CodePolicy G-14001
    Change TypeModified
    Effective DateJan 1, 202755d
    Last ReviewSep 9, 2026
    Next Review DateN/A
    Key ActionReport antepartum and postpartum E/M services per encounter with the applicable E/M code and modifier TH.
    SourceLink
    POLICY UPDATE CHANGES

    The policy replaces 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.

    The policy added a related maternity services code list and multiple definitions.

    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.

    4
    Maternity care phases addressed
    1/dayLabor management limit
    13Routine antepartum E/M limit
    3Outpatient postpartum E/M limit
    16Combined E/M visit limit
    12 weeksPost-delivery episode period

    Maternity Service Reimbursement Criteria

    Maternity Service Reimbursement Criteria

    Maternity care services are eligible for reimbursement when appropriately reported, including antepartum care, labor management, delivery, postpartum care, and related maternity services, unless provider, state, federal, CMS, or contractual requirements indicate otherwise.

    Core maternity service reporting requirements

    • Antepartum care is reported per encounter with the applicable E/M code and modifier TH.
    • The first prenatal E/M visit following confirmation of pregnancy must include an applicable ICD-10-CM code from category Z3A identifying the completed weeks of gestation.

      Required as a condition of reimbursement.

    • Labor management is reported with CPT codes 59080-59083.

      Reimbursement is limited to one labor management service per calendar date, per setting, at the highest applicable level.

    • Delivery is reported with CPT code 59431, 59432, 59502, or 59503, as applicable.
    • All professional delivery claims must include an applicable ICD-10-CM code from category Z3A identifying the completed weeks of gestation at delivery.

      Required as a condition of reimbursement.

    • Postpartum care is reported per encounter with the applicable E/M code and modifier TH.
    • An ICD-10-CM code from category Z3A is not required on postpartum E/M claims.

    Documentation and claim review

    • Medical record documentation must support the reported code, date of service, place of service, maternity care phase, E/M level or labor management complexity, required modifier, and any separately reported procedure or service.
    • The health plan may request medical records and perform prepayment or post-payment review of claims.

    Routine and high-risk pregnancy services included in antepartum reimbursement

    • The 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 as the E/M service.

      When these conditions apply, the listed services are included in the E/M reimbursement and are not separately reimbursable.

    • Included services

      • Routine urinalysis and point-of-care urine testing: CPT 81000, 81001, 81002, 81003, 81015.
      • Urine pregnancy testing: CPT 81025.
      • Preventive counseling: CPT 99401-99404.
      • Self-management education: CPT 98960-98962.

    Services and reporting circumstances not separately reimbursable

    • 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.

    • 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.
    • Labor management is reported for a scheduled or planned cesarean delivery when the patient is not in labor.
    • Immediate postpartum care is rendered on the same calendar date as delivery.
    • Hospital inpatient or observation discharge day management is reported when the patient is discharged on the same calendar date as delivery.

    Coding and Reimbursement Parameters

    Antepartum and postpartum E/M modifierModifierCovered
    Modifier THObstetrical treatment or services, prenatal or postpartum; required on antepartum and postpartum E/M services.
    Gestational age diagnosis reportingICD-10Covered
    Z3AICD-10-CM category identifying completed weeks of gestation.
    Labor managementCPTCovered
    59080-59083Labor management services.
    Delivery servicesCPTCovered
    59431Applicable delivery service.
    59432Applicable delivery service.
    59502Applicable delivery service.
    59503Applicable delivery service.
    Separately reimbursable servicesmixedCovered
    25Modifier 25 for a significant, separately identifiable E/M service performed at another site before admission for labor management.
    59300Repair of a first- or second-degree episiotomy or laceration when separately performed by another professional.
    59414Delivery of the placenta when separately performed by another professional.
    59433Repair of a third- or fourth-degree episiotomy or laceration in conjunction with vaginal delivery.
    59434Repair of a third- or fourth-degree episiotomy or laceration in conjunction with vaginal delivery.
    59504Subtotal or total hysterectomy performed during the same operative session as cesarean delivery; modifier 51 is required when reported by the same physician.
    51Modifier 51 required when the same physician reports both cesarean delivery and hysterectomy.
    59623Uterine tamponade when the procedure is performed.
    Services not separately reimbursable with antepartum E/MmixedNot Covered
    81000Routine urinalysis; included when reported under specified same-date antepartum E/M conditions.
    81001Routine urinalysis; included when reported under specified same-date antepartum E/M conditions.
    81002Routine urinalysis; included when reported under specified same-date antepartum E/M conditions.
    81003Routine urinalysis; included when reported under specified same-date antepartum E/M conditions.
    81015Routine urinalysis; included when reported under specified same-date antepartum E/M conditions.
    81025Urine pregnancy testing; included when reported under specified same-date antepartum E/M conditions.
    99401-99404Preventive counseling; included under specified same-date antepartum E/M conditions.
    98960-98962Self-management education; included under specified same-date antepartum E/M conditions.
    S9443Prenatal and lactation education; included under specified same-date antepartum E/M conditions.
    S9445Prenatal and lactation education; included under specified same-date antepartum E/M conditions.
    1–10 of 20
    1/2
    Labor management frequency
    ServiceLabor management services reported with CPT codes 59080-59083.
    Frequency limitOne labor management service per calendar date, per setting.
    Reimbursement levelReimbursement is limited to the highest applicable level.
    Routine antepartum E/M limit
    Visit limit13 routine antepartum E/M visits per pregnancy episode.
    Applies to

    Provider Reporting and Documentation Actions

    Documentation Required

    Support every billed service with medical records

    Maintain medical record documentation that supports the reported code, date of service, place of service, maternity care phase, E/M level or labor management complexity, required modifier, and any separately reported procedure or service.

    Denial Risk

    Coding and billing noncompliance may affect payment

    Claims may be subject to prepayment or post-payment medical record review. Failure to follow applicable coding and billing requirements may result in claim rejection, denial, payment recovery, recoupment, or reimbursement adjustment.

    • Ensure billed services are fully supported in the medical record or office notes.
    • Use proper, compliant codes and billing and submission guidelines.

    Maternity Care Definitions

    Antepartum care
    DefinitionManagement of the pregnancy before the onset of labor.
    ReportingReport antepartum care per encounter.
    Code requirementUse the applicable E/M code.
    Delivery
    BeginningDelivery management begins when labor is complete or interrupted.
    ScopeIt includes management of the parturient and fetus(es) through vaginal or cesarean delivery.
    Included careImmediate postpartum care on the delivery date is included.
    Policy Summary
    PayerWellpoint Maryland Medicaid
    PolicyMaternity Services
    Policy CodePolicy G-14001
    Change TypeModified
    Effective DateJan 1, 202755d
    Last ReviewSep 9, 2026
    Next Review DateN/A
    Key ActionReport antepartum and postpartum E/M services per encounter with the applicable E/M code and modifier TH.
    SourceLink
    On This Page
    Maternity Service Reimbursement CriteriaCoding and Reimbursement ParametersProvider Reporting and Documentation ActionsMaternity Care Definitions
    Prenatal and lactation education: HCPCS S9443, S9445.
  1. Behavioral screening: CPT 96127.
  2. Depression screening: HCPCS G0444.
  3. Health-risk assessments: CPT 96160, 96161.
  4. Prolonged E/M services: CPT 99417, G2212.
  5. Remote physiologic monitoring setup and device supply: CPT 99453, 99454.
  6. Tobacco cessation services: CPT 99406, 99407.
    7. 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.

    These services are included in the vaginal delivery reimbursement.

  7. Initial or subsequent hospital inpatient or observation E/M services are reported on the same calendar date as a repeat cesarean delivery.
  8. Uterine tamponade is performed when only pharmacologic management of hemorrhage is provided.
  9. Duplicate or otherwise overlapping maternity care services are reported.
    10. Routine antepartum E/M services.
    Counting periodVisits are counted within the pregnancy episode.
    Outpatient postpartum E/M limit
    Visit limit3 outpatient postpartum E/M visits per pregnancy episode.
    Applies toOutpatient postpartum E/M services.
    Counting periodVisits are counted within the pregnancy episode.
    Combined antepartum and outpatient postpartum E/M limit
    Combined limit16 combined antepartum and outpatient postpartum E/M visits per pregnancy episode.
    Included servicesRoutine antepartum and outpatient postpartum E/M visits.
    Reporting entityThe limit applies to services reported under the same federal TIN.
    Pregnancy episode duration
    StartThe pregnancy episode begins with the first pregnancy-related maternity service.
    EndThe episode ends 12 weeks after delivery.
    PurposeThe episode is used to apply routine antepartum and outpatient postpartum E/M visit limits.
    Billing Rule

    Use modifier TH for each antepartum and postpartum E/M service

    Report each antepartum and postpartum E/M service per encounter with the applicable E/M code and modifier TH. Modifier TH is required on antepartum and postpartum E/M services under this policy.

    Billing Rule

    Report gestational age at the initial prenatal E/M visit

    For the first prenatal E/M visit following confirmation of pregnancy, report an applicable ICD-10-CM code from category Z3A identifying the completed weeks of gestation as a condition of reimbursement.

    Billing Rule

    Include gestational age on professional delivery claims

    All professional delivery claims must include an applicable ICD-10-CM code from category Z3A identifying the completed weeks of gestation at delivery as a condition of reimbursement.

    Billing Rule

    Limit labor management billing to one service per date and setting

    Report labor management with CPT codes 59080-59083. Reimbursement is limited to one labor management service per calendar date, per setting, at the highest applicable level.

    High-risk pregnancy
    Required conditionA documented maternal, fetal, or obstetric condition, complication, or risk factor.
    Management needThe condition requires surveillance, evaluation, or management beyond routine maternity care.
    ClassificationA pregnancy meeting these criteria is considered high-risk.
    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 focusManagement covers the parturient and fetus(es) during the labor-management admission.
    Modifier 25
    DefinitionA significant, separately identifiable E/M service.
    ProviderPerformed by the same physician or other qualified healthcare professional.
    TimingPerformed on the same date as another procedure or service.
    Modifier TH
    DescriptionObstetrical treatment or services, prenatal or postpartum.
    Required useModifier TH is required on antepartum and postpartum E/M services under this policy.
    Applicable phasesUse applies to prenatal and postpartum services.
    Postpartum care
    DefinitionOngoing assessment and management of the patient after delivery.
    TimingPostpartum care occurs after delivery.
    ReportingReport postpartum care per encounter with the applicable E/M code.
    Pregnancy episode
    StartThe pregnancy episode begins with the first pregnancy-related maternity service.
    EndThe pregnancy episode ends 12 weeks after delivery.
    Visit limitsThe episode applies the 13-visit antepartum, 3-visit outpatient postpartum, and combined 16-visit limits 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 enhanced management.
    Excluded conditionsNo documented condition, complication, or risk factor requires surveillance, evaluation, or management beyond routine maternity care.
    Care levelManagement remains within routine maternity care.