Global Maternity Billing BCBS Guidelines and Updates

As a healthcare provider, understanding the latest guidelines for global maternity billing with BCBS is crucial to ensure smooth claims processing and reimbursement. BCBS requires hospitals and providers to submit claims using a specific set of guidelines.

BCBS has established a set of guidelines for global maternity billing, which includes specific codes and procedures for billing. The guidelines are designed to ensure that claims are processed accurately and efficiently.

According to BCBS, global maternity billing includes all services provided during a mother's stay in the hospital, from admission to discharge. This includes prenatal, delivery, and postpartum care.

BCBS requires providers to use the ICD-10-CM code for the primary diagnosis and the CPT code for the primary procedure. The guidelines also specify that the global maternity fee should be billed on the same claim as the primary procedure.

Global maternity billing guidelines can be complex, but understanding the basics can help you navigate the process. The global maternity package includes routine obstetric care, including antepartum care, delivery, and postpartum care. This package is billed by a single provider or practice group that provides all the necessary care.

The global maternity package includes the following codes: CPT 59400, CPT 59510, CPT 59610, and CPT 59618. These codes cover all the necessary services, including routine lactation services, home postpartum visits, and prenatal care. However, services unrelated to pregnancy, such as E&M services, should be reported separately.

Services that are not included in the global maternity package include complications related to lactation, IUD insertion, and medical management of postpartum depression. These services may be separately reimbursed. It's also worth noting that global maternity codes are reported for all routes of delivery, and the global period includes 280 days prior to the date of delivery and up to 45 days after the date of delivery.

Effective October 19, 2021, Blue Cross and Blue Shield North Carolina will provide reimbursement for maternity-related services according to the revised Global Maternity Reimbursement policy.

The global obstetrical professional package includes all services normally provided within routine maternity care, such as antepartum care, delivery, and postpartum care.

For facility maternity services, visit the Provider Blue Book.

Global maternity service codes should be filed when the same physician and/or other qualified health care professional or the same practice performs all the prenatal, delivery, and postpartum services during the global period.

These codes are reported for all routes of delivery.

There are several circumstances when performing prenatal, delivery, and postpartum services does not result in global billing, including when more than one practice performs maternity services during the global period, when more than one payer provides maternity benefits during the global period, when prenatal care is initiated late, or when the pregnancy ends early.

Here are the scenarios when global billing may not be applicable:

For full details on reporting and reimbursement for global maternity, please see the revised policy for Global Maternity Reimbursement.

The maternity global period is a crucial aspect of global maternity billing guidelines. It begins on the date the prenatal record is initiated and extends through the postpartum period, which is 45 days postpartum.

Our health plan has established maternity global periods, which is a deviation from the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule that assigns maternity procedure codes a global days indicator of MMM.

To report maternity services, you'll need to use a global maternity package, which includes codes for antepartum care, delivery, and postpartum care. The following codes may be used:

Services included in the global maternity reimbursement will not be reimbursed separately, including pregnancy-related E&M services provided 280 days prior to the date of delivery and up to 45 days after the date of delivery.

The global maternity period begins on the date the prenatal record is initiated and extends through the postpartum period, which is 45 days postpartum.

BCBS has established maternity global periods, and the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule assigns maternity procedure codes a global days indicator of MMM.

During uncomplicated active labor management, professional services are considered inclusive of the global OB services and are not separately reimbursable.

The maternity global period includes postpartum care only services, such as postpartum home or office visits, discussion of contraception, routine lactation services, and suture removal, which can be eligible for reimbursement with CPT code 59430.

Postpartum care only services include:

Postpartum Services are a crucial part of maternity care, providing essential support and care to new mothers.

Recovery room visits and uncomplicated inpatient hospital postpartum visits are typically included in postpartum global maternity services.

Uncomplicated outpatient visits for 45 days postpartum can take place in any setting, making it convenient for new mothers.

Discussion of contraception is also included in postpartum global maternity services.

Routine lactation services are available to help new mothers with breastfeeding.

CPT 59430 codes may be eligible for reimbursement for postpartum care only services.

Postpartum care only services include postpartum home or office visits following vaginal or cesarean section delivery.

Discussion of contraception and routine lactation services are also included in postpartum care only services.

The following services may be separately reimbursed: complications related to lactation, intrauterine device (IUD) insertion, and medical management of postpartum depression (PPD).

Latent phase of labor without OB complications is not separately reimbursable from global OB services.

During uncomplicated active labor management, professional services are considered inclusive of the global OB services and are not separately reimbursable.

Transfer of care during active labor, such as from a birthing center to a hospital, requires coordination of billing to ensure correct coding.

Unbundled, overlapping, or duplicate services are not reimbursable.

Prolonged services involving indefinite periods of time, such as labor and delivery management, are not separately reimbursable per ACOG coding guidelines.

Maternity delivery codes include uncomplicated labor management.

Modifier 22 is used to report increased procedural services, and it's often used in maternity billing. It's a crucial modifier to understand, especially when billing for global maternity codes.

To report a cesarean delivery of twins, you'll use code 59510 and modifier 22. This is a specific scenario where modifier 22 is required.

Modifier 22 can also be used when a delivery of a singleton requires substantial additional work, in which case you'll report the delivery only code.

You can report repair of third- or fourth-degree lacerations using a CPT code from the Integumentary section, or add modifier 22 to report the repair if billing the delivery only code.

Separately Reimbursable Codes are a crucial aspect of billing, and it's essential to understand what services qualify for increased reimbursement.

For OB care, separately reimbursable codes include consults made during active labor management, delivery, and postpartum, as well as the administration of general or regional anesthesia during these times.

Another scenario where separately reimbursable codes apply is when another physician or healthcare professional assumes OB care, either by member transfer or provider referral, except during intrapartum care.

When a member is delivered by another physician or healthcare professional not in the same practice, or when pregnancy is terminated or the member changes insurers, separately reimbursable codes also come into play.

For Commercial plans, home birth kits are eligible for reimbursement up to 1 kit per pregnancy, billed on the mother's claim with procedure code S8415, Supplies for Home Delivery of Infant.

To be considered for increased reimbursement, documentation from the patient's record supporting the substantially greater effort performed by the provider must be submitted with the claim.

Here are some examples of separately reimbursable codes in OB care:

Modifier 22 is a crucial code to understand in maternity billing. It's used to report increased procedural services, which means the patient required additional work beyond the standard delivery process.

Modifier 22 is appropriate in three situations. First, it's used for cesarean delivery of twins, where you'll report code 59510 only. Second, it's used for delivery of a singleton that requires substantial additional work, where you'll report the delivery only code. Third, it's used when the entire global period is complicated and necessitates greater effort than typically required, where you'll use the global code.

Repair of third- or fourth-degree lacerations at the time of delivery may be reported using a CPT code from the Integumentary section. However, if you're billing a global maternity code, you can use Modifier 22 to report the repair.

Here are some specific scenarios where Modifier 22 is used:

In these situations, Modifier 22 is used to report the increased procedural services and ensure accurate reimbursement.

The global maternity package includes routine obstetric care, including antepartum care, vaginal delivery, and postpartum care. This package is typically billed by a single provider who provides all the necessary care.

The global maternity package includes the following services:

Global obstetric services fall into three categories: antepartum care, delivery, and postpartum care. If only one physician treated a patient for an entire pregnancy, billing with a global CPT code may be appropriate.

The Global Package is a comprehensive care option for maternity services. It includes a range of services, including routine obstetric care, antepartum care, vaginal delivery, cesarean delivery, and postpartum care.

CPT codes 59400, 59510, 59610, and 59618 are used to bill for Global Maternity care when provided by a single provider group. These codes cover antepartum care, delivery, and postpartum care.

Services included in the Global Package are not separately reimbursable, such as pregnancy-related E&M services, routine lactation services, and home postpartum visits.

Here are some examples of services that are not separately reimbursable:

Procedures should be reported with the most specific CPT/HCPCS code possible, and only if all services described by that code are performed.

Global obstetric services can be complex and require caution when billing. If only one physician treated a patient for an entire pregnancy, including antepartum care, delivery, and postpartum care, billing with a global CPT code may be appropriate.

However, if an obstetrical patient requires the services of two or more different physicians during the course of pregnancy, each physician must bill for services using the appropriate CPT code that accurately describes the services they performed.

The global maternity codes, such as CPT 59400 and CPT 59618, are only for services provided by a member of the same maternity practice group. If services are provided by multiple physicians, each physician should bill separately.

Here are some examples of services that are not separately reimbursable when billed with global maternity codes:

It's essential to report procedures with the CPT/HCPCS code that describes the services performed to the greatest specificity possible and only if all services described by that code are performed. Unbundling occurs when multiple codes are used to report a procedure covered by a single comprehensive CPT/HCPCS code.

Maternity care benefits can be a bit complex, but don't worry, I'm here to break it down for you.

Postpartum care only services are eligible for reimbursement, and they include postpartum home or office visits following vaginal or cesarean section delivery.

These visits can involve discussing contraception, providing routine lactation services, and removing sutures.

Some services, like complications related to lactation, intrauterine device (IUD) insertion, and medical management of postpartum depression (PPD), may be separately reimbursed.

Here are some examples of postpartum care services that may be reimbursed:

Home birthing center deliveries and postpartum services are subject to the same reimbursement policy as services performed by physicians and other health care professionals who deliver in the hospital setting.

This means that home birthing center services will be covered by BCBS in the same way as hospital births, providing a more affordable and intimate option for expectant mothers.

In fact, home birthing center deliveries and postpartum services are treated no differently than hospital births under BCBS's reimbursement policy.

This policy ensures that all expectant mothers have access to quality care, regardless of where they choose to give birth.

To ensure a smooth global maternity billing process with BCBS, it's essential to understand their policy and caution guidelines.

Fewer than four prenatal visits do not qualify for global reimbursement. Each visit should be billed with an Evaluation & Management (E&M) code.

Routine antepartum care includes a minimum of four prenatal visits, with monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery, as recommended by The American Congress of Obstetricians and Gynceologists (ACOG).

Services to diagnose the pregnancy may be separately reimbursable, with the appropriate level of E/M service, when the pregnancy is confirmed during a problem-oriented or preventive care visit.

Other visits or services that are stated or documented in the patient's medical record as being unrelated to the pregnancy, but rendered to the patient during the maternity period, may be eligible for separate reimbursement using E&M codes or medical service codes.

Services rendered due to an unrelated condition of the pregnancy, but warrants additional management of the patient's maternity care, is eligible for separate reimbursement.

Surgical care during the antepartum period may be eligible for separate reimbursement, including procedures such as adnexal mass, hernia repair, appendicitis, etc.

Note: The following CPT codes may be eligible for reimbursement: CPT 59425 for 4-6 visits and CPT 59426 for 7 or more visits.