Obstetrical Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans
Maternity care includes antepartum care, delivery services, and postpartum care. This policy describes reimbursement for global obstetrical(OB)codesand itemization of maternity care services. In addition, the policy indicates what services are and are not separately reimbursable to other maternity services.Unless otherwise specified, for the purposes of this policySame Group Physician and/or Other Health Care Professionalincludes all physicians and/or other health care professionals of the same group reportingthe same federal tax identification number.
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Click to Download: Obstetrical Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans
Questions and Answers
Q: Will UnitedHealthcare reimburse an attending physician for fetal monitoring during labor (CPT codes 59050 or 59051)?
A: No, these codes are specifically for fetal monitoring during labor by a consulting physician.
Q: Why is CPT code 59200 considered part of the delivery service and not reimbursed separately?
A: According to ACOG's coding guidelines, CPT code 59200 performed on the day of delivery is a component included in the delivery service. Therefore, UnitedHealthcare considers this service included in the patient's delivery service and does not consider it a separately reimbursable service unless performed and reported on a date of service other than the date of delivery.
Q: If one physician performs the delivery only, and a physician in another practice (different federal tax identification number) provides all of the postpartum care, how should these services be reported?A:The physician who performs the delivery only should report the delivery only servicewithout a postpartum component.The physician who performsall of the postpartum care should report the postpartum care only code..
Q: If one physician performs the delivery only and a different physician in the samepractice (same federal tax identification number) provides all of the postpartum care, how should these services be reported?
A: Per the CPT book, the procedure code that most accurately reflects the services performed should be used. In this instance since these physicians are of the same physician group (same federal tax identification number), The appropriate CPT code that identifies both the delivery and postpartum care should be reported.
Q: How is an OB procedure reimbursed when reported by two different physicianswith the same or different federal tax identification numbers reporting a component and a global OB care code during the same global OBperiod?
A: When OBservicesare eligible for reimbursement under this policy, only one provider will be reimbursed when multiple physicians bill duplicate OBservices. UnitedHealthcare follows a "first in, first out" claim payment methodology in determining which claim will be considered for reimbursement when claims for duplicate OB servicesare received that involve component and global OB care services.
Q: Should a postpartum visit be provided within the ACOG standard six-week period?
A: The postpartum period includes routine office or outpatient postpartum visit(s) usually, but not necessarily, performed 6 weeks following delivery. If a physician routinely performs more than one postpartum outpatient visit in an uncomplicated case, the extra visit(s) is not billed separately. When a postpartum visit is scheduled, but the patient does not keep the appointment, the physician's documentation should reflect that the patient did not appear for the scheduled postpartum visit. This visit does not have to be refunded if a global OB code was previously submitted. If a patient returns tothe office well after their scheduled postpartum visit (e.g., 6 months later) this visit may be reported separately since the global period would no longer apply.
Q: Are contraceptive management services included in postpartum care?
A:UnitedHealthcarewill consider separate reimbursement for the following contraceptive management services when provided during the postpartum period.
- Insertion, non-biodegradable drug delivery implant
- Diaphragm or cervical cap fitting with instructions
- Insertion of intrauterine device, (IUD)
Q: How should the initial OB visit be reported?
A: Per ACOG guidelines, if the OB record is not initiated, then the office place of service visit should be reported separately by using the appropriate E/M CPT code (99201-99215, 99241-99245 and 99341-99350) and ICD-10-CM diagnosis code ofZ32.01. If the OB record is initiated during theconfirmatory visit, then the confirmatory visit becomes part of the global OB package and is not reported separately.
Q: What does the phrase "changes insurers" mean in relation to itemization of Obstetric (OB) Related E/M Services?
A: For the purposes of this policy, "insurer" means a third party payer. If a patient changed insurers during her OB care, the Physician or Other Qualified Health Care Professional would separate and submit the OB services that were provided in an itemized format to each insurer. For example, when reporting the antepartum care services, the code selection depends on how many visits were performed while covered under each insurer. The Physician or Other Qualified Health Care Professional should report CPTcode59426 when 7 or more visits are provided, CPTcode 59425 when 4-6 visits are provided, or an E/M visit when only providing 1-3 visits.
For purposes of this policy, "change insurers" could also mean that a patient continues to be covered under one insurer, but changes coverage for that insurer. The Physician or Other Qualified Health Care Professional should submit OB services in the same manner as if the patient had changed insurers.
Q: How are obstetrical services provided by Birthing Centers and reported on a CMS 1500 Claim Form or its electronic equivalent reimbursed?
A: Services reported by a Birthing Center on a CMS 1500 Claim Form are not treated as a professional claim and are not subject to this reimbursement policy.11Q:Can contraceptive educational consultations and/or classes for lactation, infant safety, birthing, and parenting, be submitted separately within the global OB period?A: Contraceptive educational consultations and/or classes for lactation, infant safety, birthing, and parenting, are considered part of the global package and are not separately reimbursedwhen submitted by the Same Group Physician and/or Other Health Care Professional.