Maternity Services - JF Part B

Pregnancy

Skilled medical management is appropriate throughout the events of pregnancy, beginning with the diagnosis, continuing through the peripartum period and delivery and ending after the necessary postnatal care. Surgeons and obstetricians should bill Medicare for an all-inclusive package charge intended to cover all services associated with the surgical procedure or delivery of the child. For billing services use CPT 59400 for vaginal delivery global package or CPT 59510 for caesarean delivery global package.

All expenses for surgical and obstetrical care, including preoperative/prenatal examinations and tests and postoperative/postnatal services are considered incurred on the date of delivery. This payment policy applies whether the physician bills on a package charge basis or itemizes his/her bill separately for these items.

There will be situations that cause another surgeon or obstetrician outside of the attending provider's group to deliver the child. In those situations, CPT 59409 for vaginal delivery and CPT 59514 for caesarean delivery, need to be used.

For partial maternity services, the following CPTs are used:

• Antepartum Care: CPT codes 59425-59426
• Postpartum Care Only: CPT code 59430
• One to Three Antepartum Visits Only: Evaluation and management (E/M) codes

Medical conditions that complicate labor and delivery management, (e.g., cardiac, neurological, toxemia, premature rupture of membranes) may occur and should be billed using the Medicine CPT codes and the E/M codes. Surgical complications of pregnancy may also be billed separately (e.g., bartholin cyst, appendectomy). Occasionally, a physician's bill may include charges for additional services not directly related to the surgical procedure or the delivery. Such charges are considered incurred on the date the additional services are furnished. This payment policy applies only where the charges are imposed by one physician or by a clinic on behalf of a group of physicians. Where charges are imposed by more than one physician for surgical or obstetrical services, all preoperative/prenatal and postoperative/postnatal services performed by the physician who performed the surgery or delivery are considered incurred on the date of the surgery or delivery. Expenses for the services rendered by other physicians are considered incurred on the date they were performed.

Laboratory Testing

The following tests have been recognized nationally as medically reasonable and necessary during initial and follow-up visits for the management of pregnancy.

Initial visit

When billing for laboratory tests on the initial visit for determining pregnancy, use ICD-9-CM codes V72.41, V72.42 or V72.43.

Follow-up visits

When billing for the follow up tests for a pregnant woman, use ICD-9-CM codes V22.0-V23.9.

Teaching Physicians

In the case of maternity services furnished to Medicare eligible women, Medicare applies the physician presence requirement for both types of delivery as for other surgical procedures. To bill Medicare for the procedure, the teaching physician must be present for the delivery. These procedure codes are different from other surgery codes because there are separate codes for global obstetrical care (prenatal, delivery and postpartum) and for deliveries only.

In situations where the teaching physician's only involvement was at the time of delivery, the teaching physician should bill the delivery only code. To bill for the global procedures, the teaching physician must be present for the minimum indicated number of visits when such a number is specified in the description of the code.

Infant

After the infant is delivered, items and services furnished to the infant are not covered on the basis of the mother's eligibility.

Abortion

Therapeutic termination of pregnancy is a covered Medicare benefit only for rape, incest and where the life of the mother would be endangered if the fetus were brought to term. This would include a case where the woman suffers from a physical disorder, physical illness, including a life-endangering physical condition caused by the pregnancy itself that would, as certified by a physician, placing the woman in danger of death unless an abortion is performed.

When a pregnancy resulted from rape, incest or the pregnancy is certified by a physician as life threatening to the mother, in order for such services to be covered, the G7 modifier must be appended to the following CPT codes:

• 59840
• 59841
• 59850
• 59851
• 59852
• 59855
• 59856
• 59857
• 59866

Treatment for Infertility

• See CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 20.1 for reasonable and necessary services associated with treatment for infertility are covered under Medicare.

Certified Nurse-Midwife (CNM) Services

• Noridian Certified Nurse Midwife webpage
• See CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 180 for nurse-midwife coverage guidelines.