CurrentWellpointPolicy G-14001

Maternity Services

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This policy governs Wellpoint New Jersey Medicaid reimbursement and claim-reporting requirements for antepartum care, labor management, delivery, and postpartum care. It applies to professional providers and facilities, subject to applicable provider, state, federal, CMS, and member benefit requirements.

Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyMaternity Services

Policy CodePolicy G-14001

Change TypeMaterial update

Effective DateJanuary 1, 2027

Last ReviewSep 9, 2026

Next Review DateNot specified

Key ActionReport the applicable Z3A code on the first prenatal E/M visit after pregnancy confirmation and on all professional delivery claims.

SourceLink

POLICY UPDATE CHANGES

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

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

The Related Coding section was updated by adding a maternity services code list.

Multiple definitions were added to the Definitions section.

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CurrentWellpointPolicy G-14001

Maternity Services

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Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyMaternity Services

Policy CodePolicy G-14001

Change TypeMaterial update

Effective DateJanuary 1, 2027

Last ReviewSep 9, 2026

Next Review DateNot specified

Key ActionReport the applicable Z3A code on the first prenatal E/M visit after pregnancy confirmation and on all professional delivery claims.

SourceLink

POLICY UPDATE CHANGES

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

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

The Related Coding section was updated by adding a maternity services code list.

Multiple definitions were added to the Definitions section.

4Maternity care phases addressed

1 per date/settingLabor management limit

13 / 3 / 16Pregnancy episode visit limits

Z3A requiredGestational-week coding

8Separately reimbursable services

2Claim review types

Maternity Reimbursement Coverage

General maternity reimbursement

Maternity care services are reimbursable when appropriately reported and supported by documentation. Covered services include antepartum care, labor management, delivery, and postpartum care.

ALL of the following

The service is antepartum care, labor management, delivery, or postpartum care.
The applicable service-level code and required gestational-age coding are reported.
The medical record supports the reported code, date of service, place of service, maternity care phase, E/M level or labor management complexity, required modifiers, and any separately reported procedure or service.

Separately reimbursable services

The following services may be separately reimbursable when the stated conditions are met.

ONE of

Pregnancy confirmation is reported with the applicable E/M or preventive medicine service when antepartum care is not initiated during the encounter.
A significant, separately identifiable E/M service is performed at another site before admission for labor management and reported with modifier 25.
Labor management is rendered on the same calendar date as delivery.
Hospital inpatient or observation E/M services are reported on the same calendar date as a planned primary cesarean delivery when the patient is not in labor.
A first- or second-degree episiotomy or laceration repair is reported with CPT 59300, or delivery of the placenta is reported with CPT 59414, when performed by a physician or other qualified healthcare professional other than the professional reporting the vaginal delivery.

Not separately reimbursable services

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

ONE of

ALL of the following
- For a routine or high-risk pregnancy, a specified service is reported on the same calendar date as an applicable antepartum office or other outpatient E/M service, with an applicable maternity diagnosis and under the same TIN as the E/M service.
- The specified service is routine urinalysis or point-of-care urine testing (81000, 81001, 81002, 81003, or 81015); urine pregnancy testing (81025); preventive counseling (99401-99404); self-management education (98960-98962); prenatal or lactation education (S9443 or S9445); behavioral screening (96127); depression screening (G0444); health-risk assessment (96160 or 96161); prolonged E/M service (99417 or G2212); remote physiologic monitoring setup or device supply (99453 or 99454); or tobacco cessation service (99406 or 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 Categories

Antepartum and postpartum reportingmixedCovered

E/M	Applicable evaluation and management code for antepartum care reported per encounter and postpartum care reported per encounter
Z3A	ICD-10-CM category identifying completed weeks of gestation

Labor managementCPTCovered

59080-59083

Labor management services

DeliverymixedCovered

59431	Applicable delivery code
59432	Applicable delivery code
59502	Applicable delivery code
59503	Applicable delivery code
Z3A	ICD-10-CM category identifying completed weeks of gestation at delivery

Separately reimbursable servicesmixedCovered

25	Modifier for significant, separately identifiable E/M service performed on the same date as another service
59300	Repair of first- or second-degree episiotomy or laceration when performed by a different professional than the vaginal delivery provider
59414	Delivery of placenta when performed by a different professional than the vaginal delivery provider
59433	Repair of third- or fourth-degree episiotomy or laceration in conjunction with vaginal delivery
59434	Repair of third- or fourth-degree episiotomy or laceration in conjunction with vaginal delivery
59504	Subtotal or total hysterectomy performed during the same operative session as cesarean delivery
51	Multiple-procedure modifier required when the same physician reports cesarean delivery and hysterectomy
59623	Uterine tamponade when the procedure is performed

Services included in antepartum E/M reimbursementmixedNot Covered

81000	Routine urinalysis or point-of-care urine testing
81001	Routine urinalysis or point-of-care urine testing
81002	Routine urinalysis or point-of-care urine testing
81003	Routine urinalysis or point-of-care urine testing
81015	Routine urinalysis or point-of-care urine testing
81025	Urine pregnancy testing
99401-99404	Preventive counseling
98960-98962	Self-management education
S9443	Prenatal and lactation education
S9445	Prenatal and lactation education

1–10 of 20

1/2

Labor management frequency

FrequencyOne labor management service per calendar date and per setting.

Reimbursement levelReimbursement is limited to the highest applicable level.

Reporting codesReport labor management with CPT codes 59080-59083.

Antepartum visit limit

Antepartum limit13 visits per pregnancy episode.

Services includedRoutine antepartum E/M visits are subject to this limit.

Provider Billing and Documentation Requirements

Billing Rule

General Reimbursement and Coverage Conditions

Report maternity care services only when appropriately coded and supported, and subject to applicable provider, state, federal, CMS, contract, authorization, medical-necessity, and member-benefit requirements. Use compliant CPT, HCPCS, ICD-10-CM, and/or revenue codes as applicable.

Services must satisfy the member’s benefit-plan coverage, authorization, and medical-necessity requirements; coverage does not guarantee reimbursement.
Provider, state, federal, CMS, or contractual requirements may supersede this reimbursement policy.
Unless otherwise specified, the policy applies to participating and non-participating professional providers and facilities.

Documentation Required

Documentation Requirements

Maternity Care Definitions

Antepartum care

DefinitionManagement of the pregnancy before the onset of labor.

ReportingAntepartum care is reported per encounter.

CodeReport the applicable evaluation and management code.

Delivery

DefinitionManagement of the parturient and fetus(es) beginning when labor is complete or interrupted.

Delivery scopeManagement continues through vaginal or cesarean delivery.

Included careImmediate postpartum care on the delivery date is included.

Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyMaternity Services

Policy CodePolicy G-14001

Change TypeMaterial update

Effective DateJanuary 1, 2027

Last ReviewSep 9, 2026

Next Review DateNot specified

Key ActionReport the applicable Z3A code on the first prenatal E/M visit after pregnancy confirmation and on all professional delivery claims.

SourceLink

On This Page

A third- or fourth-degree episiotomy or laceration repair is reported with CPT 59433 or 59434 in conjunction with CPT 59431 or 59432 when performed at the time of vaginal delivery.

A subtotal or total hysterectomy is performed during the same operative session as a cesarean delivery and reported with CPT 59504; modifier 51 is used when the same physician reports both the cesarean delivery and hysterectomy.

Uterine tamponade is reported with CPT 59623 when the procedure is performed.

Interim physical examinations, collection and interpretation of physiologic data, maternal or 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.

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.

Initial or subsequent hospital inpatient or observation E/M services are reported on the same calendar date as a repeat cesarean delivery.

Uterine tamponade involves only pharmacologic management of hemorrhage.

Maternity care services are duplicate or otherwise overlapping.

ApplicationThe limit applies per pregnancy episode to services reported under the same federal TIN.

Outpatient postpartum visit limit

Postpartum limit3 outpatient postpartum visits per pregnancy episode.

Visit typeThe limit applies to outpatient postpartum E/M visits.

ApplicationThe limit applies per pregnancy episode to services reported under the same federal TIN.

Combined pregnancy episode visit limit

Combined limit16 antepartum and outpatient postpartum visits combined per pregnancy episode.

ComponentsThe combined limit consists of the 13-visit antepartum limit and the 3-visit outpatient postpartum limit.

ApplicationThe 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 pregnancy episode ends 12 weeks after delivery.

PurposeThe episode is used to apply routine antepartum and outpatient postpartum E/M visit limits.

Maintain medical records and office notes that fully support every reported maternity service and code. Documentation must support the service details and billing circumstances, including the applicable maternity care phase and any separately reported service.

Reported code and service performed
Date of service and place of service
Maternity care phase
E/M level or labor-management complexity
Required modifier
Any separately reported procedure or service

Denial Risk

Review and Denial Risk

The health plan may request medical records and review claims before or after payment. Claims that do not follow applicable coding, billing, documentation, authorization, or medical-necessity requirements may be rejected or denied, adjusted, or subject to recovery or recoupment.

Prepayment and post-payment review may be performed.
Unsupported, duplicate, overlapping, or otherwise noncompliant maternity services may be denied.
The plan may recoup or recover payment, including retroactively to the policy effective date when permitted.

Billing Rule

Gestational-Age Coding

Report the applicable ICD-10-CM code from category Z3A identifying completed weeks of gestation when required. The code is required on the first prenatal E/M visit after pregnancy is confirmed and on all professional delivery claims as a condition of reimbursement.

Report the applicable Z3A code on the first prenatal E/M visit following confirmation of pregnancy.
Report the applicable Z3A code identifying completed weeks of gestation at delivery on professional delivery claims.
A Z3A code is not required on postpartum E/M claims.

Billing Rule

Labor Management Reporting

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

Do not report more than one labor-management level for the same calendar date and setting; when multiple levels are reported, reimbursement is limited to the highest applicable level.
Interim examinations, physiologic-data collection and interpretation, maternal and fetal monitoring, and labor induction or augmentation performed as part of labor management are not separately reimbursable.
Labor management for a scheduled or planned cesarean delivery when the patient is not in labor is not separately reimbursable.

Billing Rule

Modifier Requirements

Apply the modifier required by the circumstances of the service when reporting separately identifiable services or multiple procedures. Documentation must support the distinct service, the modifier, and the applicable reporting requirements.

Use modifier 25 for a significant, separately identifiable E/M service performed at another site before admission for labor management.
Use modifier 51 when the same physician reports both a cesarean delivery and a subtotal or total hysterectomy performed during the same operative session; report the hysterectomy with CPT 59504.
Report separately reimbursable services only when they are distinct from the included maternity service and are performed under the applicable policy conditions.
Labor management may be separately reported on the same calendar date as delivery when rendered, subject to the one-service-per-calendar-date-and-setting limit.
Services that are included in the applicable maternity reimbursement, including duplicate or overlapping services, must not be separately reported for reimbursement.

High-risk pregnancy

DefinitionA pregnancy with a documented maternal, fetal, or obstetric condition, complication, or risk factor.

Required circumstanceThe condition, complication, or risk factor requires surveillance, evaluation, or management beyond routine maternity care.

Risk domainsThe documented concern may be maternal, fetal, or obstetric.

Labor management

DefinitionIntegrated decision-making and management of the parturient and fetus(es).

Facility settingThe parturient is admitted to a facility for labor management or induction.

ScopeThe service includes management during the facility admission for labor management or induction.

Modifier 25

DefinitionIndicates that a significant, separately identifiable evaluation and management service was performed.

ProviderThe service was performed by the same physician or other qualified healthcare professional.

TimingThe E/M service was performed on the same date as another procedure or service.

Modifier TH

DefinitionObstetrical treatment or services, prenatal or postpartum.

Prenatal applicabilityModifier TH describes prenatal obstetrical treatment or services.

Policy limitationModifier TH is not required on antepartum and postpartum E/M services under this policy.

Postpartum care

DefinitionOngoing assessment and management of the patient after delivery.

TimingPostpartum care occurs after delivery.

ReportingPostpartum care is reported per encounter with the applicable evaluation and management code.

Pregnancy episode

StartThe pregnancy episode begins with the first pregnancy-related maternity service.

EndThe pregnancy episode ends 12 weeks after delivery.

PurposeIt is used to apply the routine antepartum and outpatient postpartum E/M visit limits.

Routine pregnancy

DefinitionA pregnancy without a documented maternal, fetal, or obstetric condition, complication, or risk factor.

Management standardThe pregnancy does not require surveillance, evaluation, or management beyond routine maternity care.

Risk statusNo documented condition, complication, or risk factor requires enhanced management.