Effective Date: March 29, 2021
To provide guidelines for the reimbursement of maternity care for professional providers.
- NJ FamilyCare/Medicaid
- Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
Horizon NJ Health shall consider for reimbursement each individual component of the obstetrical global package as follows:
Antepartum Care Only:
Antepartum care includes the routine prenatal visits consisting of initial and subsequent histories, physical examinations, recording of weight, blood pressures, fetal heart tones, and routine chemical urinalysis.
In situations where antepartum care only services are performed, the code billed must be based on the number of visits the patient was seen during the antepartum period:
- For 1 to 3 visits: Use the appropriate evaluation/management (E/M) CPT code 99202-99215
- For 4 to 6 visits: Use CPT code 59425
- For 7 or more visits: Use CPT code 59426
Once the appropriate code is selected, the below billing guidelines must be followed:
- When billing an E/M code for a patient seen 1-3 times, each date is reported individually with the corresponding visit date
- When billing CPT code 59425 or 59426 for antepartum care only, report a single claim submission after the sessions have been completed
- The units reported should be one (1)
- The dates reported should be the range of time the patient was seen with the “from” and “to” dates when services were rendered
- For example, if the patient had a total of 4 antepartum visits, starting with 6/1/21 and ending 9/1/21, the provider should report CPT code 59425 on one claim line with one unit for dates of service 06/01/2021 to 09/01/2021.
The initial office visit for the diagnosis of pregnancy is not included in global obstetric services and should be billed with the appropriate evaluation/management (E/M) CPT code.
Depending on the delivery method, the following codes should be utilized:
- Vaginal delivery only (with or without episiotomy and/or forceps): Use CPT code 59409
- Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care: Use CPT code 59510
- Cesarean delivery only: Use CPT code 59514
- Cesarean delivery; including postpartum care: Use CPT code 59515
- Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps): Use CPT code 59612
- Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care: Use CPT code 59614
- Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery: Use CPT code 59620
- Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care: Use CPT code 59622
Delivery codes include the admission to the hospital, the admission history and physical, artificial rupture of membranes (If performed), intravenous induction of labor (If performed), a history and physical, a vaginal delivery (with or without episiotomy or forceps) or a cesarean delivery, delivery of placenta, and repairs of first or second degree lacerations as needed.
Claims for delivery services must include the gestational age diagnosis code (Z3A.XX). Horizon NJ Health will deny any delivery service claim that does not include such diagnosis code. Also see: Horizon’s Early Elective Deliveries reimbursement policy.
Postpartum Care Only:
In situations where only postpartum care is performed, CPT code 59430 should be billed. Postpartum care includes hospital and office visits following delivery. Discussion of contraception is included in postpartum care and should not be reimbursed separately.
If a delivery code was billed that includes postpartum care (59510, 59515, 59614 or 59622), the postpartum only care code will not be considered for reimbursement.
When a pregnant woman is having multiple babies delivered vaginally, the first delivery should be the appropriate ‘delivery only’ or ‘delivery and postpartum care’ code. For each additional vaginal delivery, the appropriate “vaginal delivery only” code (CPT code 59409 or 59612) must be reported with modifier -59 and will be allowed at 50% of the normal reimbursement.
Additional reimbursement will not be provided for multiple babies delivered by cesarean section.
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
Horizon NJ Health will not consider for reimbursement antepartum care only codes 59425 or 59426 when billed for more than one unit. In addition, Horizon NJ Health shall not consider for reimbursement claims that are billed for antepartum only codes for single dates of service.
Horizon NJ Health will not consider for reimbursement of postpartum care only services, CPT code 59430, when a delivery only code was billed that also includes postpartum care (CPT codes 59510, 59515, 59614 and 59622) during the same pregnancy.
Horizon NJ Health will not consider for reimbursement any delivery service code that does not include a claim with the gestational age diagnosis code (Z3A.XX).
Horizon NJ Health will not consider for reimbursement duplicative services. Services billed that are included within each component of the obstetrical package will not be considered for separate reimbursement.
American College of Obstetricians and Gynecologists (ACOG)
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services
Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:
- Benefit Limitations
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Medical necessity; and
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.