When the Family Physician Does Not Provide the Global Service

For a variety of reasons, some women receive prenatal care from more than one physician. Thus, the CPT included codes for "antepartum care only." However, CPT has divided the reporting requirements into three codes depending on how many visits the patient seeks care.

If a physician sees a pregnant woman only one to three times, the physician codes those visits using the appropriate level of office visit (CPT 99201-99215) for each visit.

If a physician sees a woman more than three but less than seven times, the physician uses code 59425, Antepartum care only; 4-6 visits.

Finally, if a physician provides seven or more visits, the physician uses CPT code 59426, Antepartum care only; 7 or more visits. Each of these codes is designed to include the "new OB visit."

Patients often ask their family physicians during their antepartum care to provide a variety of medical or surgical services. However, the antepartum codes or the global maternity care codes do not cover caring for conditions such as URI, pharyngitis, UTI, pyelonephritis, etc., and the physician should code and bill these services separately at the time of service (CPT 99201-99215).

What if the physician sees a patient for a medical complaint (e.g., URI) and a routine maternity visit on the same day?

If the payer recognizes the provision of two office services on a single date, the physician should report the problem-oriented service using modifier -25 with the evaluation and management service (E/M) code. Modifier -25 is for "Significant, separately identifiable Evaluation and Management Service by the same physician on the same day of the procedure or other service." Note the phrase, "or other service." This phrase includes other evaluation and management services, so it is possible in certain circumstances under CPT to code more than one office service provided to the same patient on the same day, if the services are significant and separately identifiable. When addressing a significant problem in the same encounter as prenatal care, it is important that documentation of the problem-oriented services is distinct from that of the prenatal care and meets the documentation requirements for the level of E/M code reported.

It is important to report the E/M service for significant evaluation and management services rendered at the time of a maternity care visit within the timely filing policy of the payer. If these charges are held and reported after delivery, charges outside of the global prenatal care may be denied due to untimely filing.

Since some carriers do not recognize two office services provided on the same day, most family physicians have these options:

Option b. describes what most family physicians do, and it is advantageous to the patient's schedule. However, option c. is equally convenient for the patient and more financially prudent for the physician.

When negotiating contracts with payers, it may be possible to include provision for payment of maternity care services by CPT guidelines by addressing the inconvenience to patient and possibly lost work hours to the employer if the patient must come in twice for services. Both the AAFP and American College of Obstetrics and Gynecology advocate that those significant, separately identifiable services provided during the routine maternity global period should be separately paid, as CPT guidelines indicate. For a sample letter requesting reconsideration of non-routine services during the maternity global period, see Sample Letter to Payer.

The CPT manual states, "For medical complications of pregnancy (e.g., cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, pre-term labor, premature rupture of membranes), see services in the Medicine and Evaluation and Management Services section." In addition, the manual states, "For surgical complications of pregnancy (e.g., appendectomy, hernia, ovarian cyst, Bartholin cyst), see services in the Surgery section." This means that family physicians should code a high-risk pregnancy with medical complications of pregnancy using office codes during the antepartum period.

Likewise, labor that is pre-term, post-term, induced, augmented or otherwise complicated (bleeding, PROM, blood pressure problems, cardiac problems, arrest of labor, fetal distress, etc.) and admissions during pregnancy that do not result in delivery are not routine and require additional time and resources. Thus, physicians should code these situations with hospital evaluation and management codes.

If the pregnancy was high-risk or had medical or surgical complications, then the physician should consider using visit codes (office or hospital) for postpartum care in addition to any other laboratory or evaluation and management services provided.

For vaginal delivery without complications, the physician who does not provide antenatal care should use one of the following codes:

For cesarean delivery without complications, the physician not providing antenatal care should use one of the following codes:

If the family physician is not involved in the delivery of the patient, either because a consultant comes in to do a complicated vaginal delivery or a cesarean delivery, then the family physician cannot use either the delivery codes or the global maternity care codes to describe his or her services. Other codes must be utilized.

If a family physician is requested by a delivering physician to attend the delivery (as in the case of vaginal birth after C-section), the family physician may bill for this service with code 99464. This is billed in addition to any history and examination performed on the newborn. See Attendance at Delivery and Stabilization for more information on reporting code 99464.

If a family physician calls in a consultant to perform a cesarean delivery and the family physician assists at surgery, the consultant will usually use code 59514 (cesarean delivery only). To report his or her services, the family physician should use code 59514 with modifier -80. This indicates the family physician provided surgical assistant services. The CPT book states, "Assistant Surgeon: Surgical assistant services may be identified by adding the modifier '-80' to the usual procedure number(s)."

The family physician would then describe all intrapartum services taking place before the consultation by using the appropriate evaluation and management codes. For example, the family physician might bill the admission history and physical as "initial hospital care" (99221-99223), as well as charging for his or her time by using, if appropriate, the "critical care" (99291, 99292) codes or the "prolonged services" (99356-99359) codes as appropriate.

If a physician does not handle the delivery but does provide postpartum care, the physician should use code 59430. This includes hospital and office visits, but it does not include any lab services provided at the postpartum visit (e.g., Pap, blood work, etc.).

If the family physician provides postpartum care along with a consultant, then only one of the physicians may use code 59430. The other physician should code these services in the same manner as any other concurrent care services by utilizing the subsequent hospital care codes (99231-99238). Each physician will need to use different diagnosis codes.