Insurance trends are shifting from fee-for-service models to global billing structures including in the area of maternity care pricing: a flat rate fee for (almost) all services rendered to cover the entire pregnancy billed with one code such as CPT code 59400.
Correctly including what is part of a global billing model – and what is not – is critical for front desk, billing and clinical staff. Get it wrong – and you’ll anger patients and lose out on pay with incorrect charge amounts.
The concept seems a win-win for all involved. From a patient perspective, a global pricing structure might offer just one deductible to meet for the entire pregnancy. This makes quality maternity care a more affordable option for pregnant women.
From a provider’s perspective, a global billing model such as with CPT code 59400 cuts down on the number of invoices to manage and claims to file claims. With a set reimbursement rate, providers can focus on patient care.
Overall, global billing for maternity eases the burden for both patient and provider. For example, an obstetrics office could bill CPT code 59400 to cover office visits, a vaginal delivery, and postpartum care, as opposed to separate codes for individual visits or separately billing the antepartum period, delivery, and postpartum period. If you are part of an ob team – front desk, coding or practice management, you should be mindful of the complexity of the patient’s course and the most up-to-date coding guidelines. Otherwise, you may give patients incorrect info or not capture the maximum ethical reimbursement. Read on for some CPT code 59400 coding and billing basics.
Global Billing with CPT Code 59400-59618 Includes These Services
The Global OB package covers patient care during the entire pregnancy — the antepartum period, delivery, and postpartum. Physicians get paid a flat rate for the services rendered under these CPT global obstetric codes:
- 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
When billing with the global OB codes, front desk staff, coders and billers need to be aware of visits and services that aren’t part of routine maternity care. This allows schedulers to provide accurate information on possible patient costs and billers to charge separately.
Proper global package code selection is essential to receive the maximum allowed reimbursement. There are times when one code might be paid but using the correct code will bring higher insurance payment. For example, if a patient has a cesarean delivery after an unsuccessful attempt at a vaginal delivery, code 59510 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, 67.00 relative value units) is in order.
However, if this same scenario transpires after a prior cesarean delivery, 59618 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery, 67.88 RVUs) is the proper code to use.
CPT Code 59400 Includes Only Uncomplicated Services
It’s important to note, global maternity billing covers services under normal, uncomplicated conditions. Global maternity billing does not cover:
- Problems that aren’t related to pregnancy, such as yeast infections
- Services for pregnancy complications, such as gestational diabetes or toxemia
- Extra visits for a high-risk pregnancy
- Procedures, such as ultrasounds and amniocentesis
Instead, the physician would separately bill these services at the time of treatment.
Insurers Vary on CPT Code 59400 Billing, Payment Schedule, Duration
Global billing for maternity care is beneficial to both patient and physician when the pregnancy follows an uncomplicated course. Some variables, however, can complicate matters for the physician’s revenue cycle.
Considering the global maternity billing package spans a nine-month period, that’s a big window to wait for reimbursement. Variables to consider with insurance companies when billing for global maternity services are:
- Not all insurance companies handle global maternity billing the same way.
- Not all insurers pay physicians at the same interval. Some pay at the start of the pregnancy while others pay after the final postpartum visit is complete.
- Insurers differ on the coverage of specific services and duration of the global pricing bundle.
CPT Code 59400 Doesn’t Always Apply
The CPT ob bundles are billed for and reimbursed when all services are rendered by a single physician or multiple physicians from the same group.
There are some situations that complicate global maternity billing and require the physician to bill the delivery, antepartum, and postpartum separately. These include when a:
- patient must change insurance providers or doctors during her pregnancy
- patient’s baby is delivered by someone other than her physician or another physician in a group practice
- patient has a voluntary or involuntary pregnancy termination