Prenatal office visits

Applies to members of:

All plans, except self-funded plans with a Maternity exclusion for dependents

Routine maternity services coverage

Routine maternity services are not synonymous with preventive benefit with no cost share. Consult plan documents for specific routine maternity benefits. 

Self-funded plans with a Maternity exclusion for dependents will deny all services except routine lab work.

Clinical edit: Obstetric Services, Global Care

Claims will deny Evaluation and Management services (99202-99215) when billed with a diagnosis of post-partum care uncomplicated postpartum care (ICD-10 codes Z39-Z39.2), contraceptive management (ICD-10 codes Z30.011, Z30.013-Z30.09), or family planning advice when a delivery care only service (59409, 59514, 59612, 59620) has been billed in the past 42 days (6 weeks) by any provider.

AMA CPT manual instructs postpartum care cannot be reported as a separate E/M service during the postpartum period, whether performed by the same provider who performed the delivery or by a different provider. Postpartum care is correctly reported.

For both professional and facility claims, claims will be denied when a delivery procedure code is billed and an outcome of delivery diagnosis isn't also reported on the claim. This is in accordance with Chapter 15 of the ICD-10 official coding and reporting guidelines.

Prenatal visits billing

Prenatal care, individual visits (3 or fewer)

You may need to itemize services when:

  • Prenatal care is irregular or late
  • Member experiences a miscarriage or terminates pregnancy
  • Member changes OB provider
  • Member changes insurance company 

Billing instructions:

  • Bill all visits at the end of the treatment period, which may be defined by one of the reasons listed above.
  • Code: Use an appropriate level of E&M code
  • From/To dates (Box 24A CMS-1500): List date of service on each line for each E&M code billed
  • Quantity (Box 24G CMS-1500): Indicate unit of 1 for each E&M code billed. Total number of lines should not exceed 3.
  • Fill in the EXACT LMP date in box 14 of the CMS-1500.
  • Other considerations apply when a patient is treated for an illness.

Prenatal services only (no delivery associated with the visits)

Bill the global prenatal service package code at the end of the treatment period, not separately at every visit.

  • Codes: Use 59425 to bill 4 to 6 visits, 59426 to bill 7 or more visits
  • From/To dates (Box 24A CMS-1500): Indicate first prenatal visit as the "from/to" date.
  • Quantity (Box 24G CMS-1500): One
  • Notes section: List prenatal visit dates or claim will deny.
  • Fill in the EXACT LMP date in box 14 of the CMS-1500.
  • Other considerations apply when a patient is treated for an illness.

Prenatal package with delivery and postpartum care (7 or more prenatal visits)

Bill global package following delivery, entering the delivery date for the date the service was provided. Note: The post-partum visit is inclusive to this and not separately payable within a 42-day period for normal delivery.

  • Codes: Use 59400, 59510, 59610, and 59618
  • From/To dates (Box 24A CMS-1500): Indicate delivery date
  • Quantity (Box 24G CMS-1500): One
  • Place of service: Inpatient
  • Notes section: List prenatal visit dates or claim will deny.
  • Fill in the EXACT LMP date in box 14 of the CMS-1500.
  • Other considerations apply when a patient is treated for an illness.

High-risk pregnancies

When the patient has a high-risk prenatal condition, you may perform additional services that fall outside of the normal prenatal package.

For high-risk pregnancy visits that exceed the average number of normal prenatal visits, report the E&M service.

Payable when:

  • Visits are required outside of the normal prenatal visit schedule
  • The diagnosis is the high-risk condition
  • Services monitor or treat the high-risk condition
  • Medical record documents the ongoing concern

Visits for illness during prenatal period

When a patient is treated incidentally for a problem unrelated to her prenatal care on the same date as the prenatal visit, include the visit as part of routine prenatal care. Copayment will apply to the prenatal maximum.

If an office visit for an illness is scheduled outside of the planned interval for prenatal care:

  • Take the regular office visit copayment (does not apply to prenatal maximum)
  • Documentation for E&M services billed for "sick" diagnosis should be complete and separate from the OB record
  • Bill the appropriate E&M code for the illness presented and care rendered
  • List the illness diagnosis code as primary
  • Submit bill at the time of service
  • Do not include in listing of prenatal visits when billing the OB package code

When additional information may be needed

Priority Health returns claims for additional information in some cases. Examples include:

  • Member became effective with Priority Health during the pregnancy: Another insurance plan or the member would be responsible for a portion of the payment for services
  • Member loses coverage during pregnancy
  • Member changes from a Priority Health self-funded plan to a Priority Health fully funded plan, or vice versa (payer changes from the employer to Priority Health or vice versa)