Billing and coding can be one of the most confusing—and financially important—aspects of running a midwifery practice.

A midwife can provide exceptional clinical care, see a full schedule, attend births, complete meticulous documentation, and still experience significant financial problems if the billing, coding, documentation, and reimbursement systems aren’t working together.

For midwifery practice owners, billing isn’t simply an administrative task.

It is a core business function.

Every service that is appropriately documented, coded, submitted, and reimbursed contributes to the financial health of the practice.

At the same time, billing and coding must be approached carefully. Codes, payer policies, Medicaid requirements, global maternity rules, modifiers, documentation requirements, and reimbursement policies vary by payer and can change over time. The information below is educational and should not replace current payer guidance, official coding resources, or advice from a qualified coding/billing professional.

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1. Understand the Difference Between Coding and Billing

These terms are often used interchangeably, but they aren’t the same thing.

Coding

Coding translates the clinical services and diagnoses documented in the medical record into standardized codes.

This may involve:

• CPT
• HCPCS
• ICD-10-CM
• Modifiers
• Place-of-service codes

Billing

Billing is the process of submitting those coded services to the appropriate payer or patient and managing the claim through payment or resolution.

Think of it as:

Clinical care → Documentation → Coding → Claim → Payer processing → Payment

A problem at any point can affect revenue.

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2. Don’t Code What You Didn’t Document

One of the most important principles in healthcare billing is:

The medical record must support the services reported.

A midwife shouldn’t select a higher-level service simply because the practice needs more revenue.

Instead:

Document the care you provided.

Then:

Code what the documentation supports.

Then:

Submit according to the applicable payer requirements.

This protects both the practice and the integrity of the billing process.

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3. Know Your Scope of Practice

Before billing for a service, make sure the service is:

• Within your legal scope of practice
• Within your education and training
• Permitted under your credentialing
• Covered by the applicable payer
• Properly documented

Scope of practice and reimbursement are related but aren’t identical.

A service can be clinically appropriate but still have payer-specific billing limitations.

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4. Understand Your NPI and Credentialing

Every midwifery practice should have a clear understanding of the National Provider Identifier (NPI) structure applicable to its organization and individual clinicians.

Depending on the business model, you may encounter:

• Individual NPIs
• Organizational NPIs
• Tax IDs
• Payer enrollment
• Credentialing
• Recredentialing
• CAQH information

Credentialing problems can become billing problems.

If a provider isn’t properly enrolled or credentialed with a payer, claims may be denied even when the clinical service itself was appropriate.

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5. Know Which Payers You Are Contracted With

Don’t assume that because a payer reimburses midwives, your practice is automatically in-network.

Know:

• Which plans you participate with
• Which products are included
• Your effective dates
• Your contracted rates
• Your provider status
• Any location restrictions
• Prior authorization requirements
• Referral requirements

Keep copies of your contracts and fee schedules.

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6. Understand Your Fee Schedule

Every practice should have a written fee schedule.

It should identify the charges associated with services you routinely provide.

Depending on the practice, this might include:

• Prenatal visits
• Postpartum visits
• Well-woman services
• Gynecologic services
• Contraceptive services
• Birth services
• Newborn services
• Lactation-related services
• Ultrasound services
• Procedures
• Laboratory services
• Education or classes

Your charge is not necessarily what you will be paid.

That’s an important distinction.

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7. Charges, Allowed Amounts, and Payments Are Different

For example:

You might charge:

$300

The payer’s allowed amount might be:

$180

The payer may then reimburse:

$150

with the remaining amount handled according to the contract, patient responsibility, or applicable billing rules.

Therefore, looking only at your fee schedule doesn’t tell you whether your practice is financially healthy.

You need to understand your actual reimbursement.

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8. Understand Global Maternity Billing

This is particularly important for midwives providing comprehensive maternity care.

Depending on the payer and circumstances, maternity services may be reimbursed through:

• Global maternity packages
• Individual antepartum services
• Delivery services
• Postpartum services
• Other separately reportable services when appropriate

But global maternity billing rules are highly payer-specific.

Don’t assume that one payer’s rules apply to another.

Before billing, determine:

• What the payer considers global
• What services are included
• When a service may be separately reported
• How partial care is handled
• How transfers are handled
• What happens when another provider performs part of the care

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9. Understand Split or Partial Maternity Care

Patients don’t always receive their entire pregnancy and postpartum care from one provider.

They may:

• Transfer into your practice
• Transfer out
• Move
• Change insurance
• Require higher-level care
• Deliver somewhere else

Your billing process needs to account for these situations.

Document clearly:

When care began.

What care was provided.

When care ended.

Why care ended.

Who assumed care afterward.

Then follow the applicable payer rules for reporting the services.

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10. Don’t Assume Every Visit Is Included in a Global Package

One common billing mistake is assuming:

“It’s maternity care, so everything is global.”

That’s not necessarily true.

There can be services that have different billing rules depending on:

• Type of service
• Clinical circumstances
• Timing
• Payer
• Documentation
• Whether the service is considered part of routine maternity care

This is why your practice needs a payer-specific billing reference.

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11. Documentation Is Your First Line of Defense

Good documentation supports:

Clinical care.

Coding.

Billing.

Medical necessity.

Compliance.

Appeals.

A strong note should clearly communicate what happened during the encounter.

Avoid documentation that is:

“Routine prenatal visit. Doing well.”

when the encounter actually involved substantial assessment, counseling, education, decision-making, or management.

Document what you actually did.

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12. Don’t Copy-and-Paste Your Way Into a Problem

Templates can be extremely useful.

But copied documentation can create problems when the record contains:

• Contradictory information
• Outdated information
• Findings that weren’t actually assessed
• Services that weren’t performed
• Incorrect gestational age
• Incorrect medications
• Incorrect patient information

Templates should support clinical documentation—not replace it.

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13. Know Your ICD-10-CM Codes

Diagnosis coding is an important part of the claim.

Depending on the encounter, coding may involve factors such as:

• Pregnancy
• Trimester
• Supervision
• Complications
• Medical conditions
• Symptoms
• Routine preventive care
• Gynecologic conditions

Pregnancy-related ICD-10-CM coding can be particularly detailed.

Don’t guess.

Use current official coding resources and payer guidance.

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14. Pay Attention to Pregnancy Trimester

For many obstetric diagnosis codes, trimester matters.

That means your documentation needs to support the appropriate stage of pregnancy.

Accurate documentation should make it possible to determine:

• Gestational age
• Trimester
• Relevant pregnancy conditions
• Whether the encounter is related to pregnancy

A coding error involving trimester can result in a claim denial or incorrect reporting.

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15. Don’t Forget Modifiers

Modifiers can provide additional information about how a service was performed or billed.

However:

A modifier isn’t a tool for getting a claim paid.

It should be used only when appropriate and supported by the coding rules and payer requirements.

Common examples across healthcare include modifiers such as:

• 25
• 59
• 52
• 53
• 24

But whether a particular modifier is appropriate depends on the actual circumstances and payer rules.

Never add a modifier simply because:

“The claim was denied last time.”

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16. Understand Place of Service

Midwives who provide care in different locations need to pay particular attention to place-of-service coding.

Your services might occur in:

• Office
• Patient’s home
• Birth center
• Hospital
• Other healthcare locations

The place of service can affect claim processing and reimbursement.

Your billing system should accurately reflect where the service occurred.

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17. Home Birth Practices Need Especially Strong Documentation

Home birth billing can involve unique operational considerations.

Document appropriately:

• Location
• Date
• Time
• Services provided
• Clinical findings
• Labor management
• Delivery
• Maternal status
• Newborn-related services within your scope
• Postpartum care
• Transfers when applicable

Don’t rely on memory.

Birth documentation should be completed promptly and accurately.

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18. Birth Center Billing Requires a Different Level of Business Attention

Birth centers can have more complex billing environments because there may be:

• Facility considerations
• Professional services
• Multiple providers
• Facility fees
• Supplies
• Laboratory services
• Separate organizational billing
• Payer-specific requirements

If your birth center is billing both professional and facility services, make sure you understand which entity is billing for which service.

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19. Don’t Ignore Denials

A denied claim isn’t necessarily lost revenue.

Create a denial-management process.

Track:

• Patient
• Date of service
• Payer
• CPT/HCPCS
• ICD-10-CM
• Denial reason
• Amount
• Corrective action
• Appeal status
• Resolution

Then look for patterns.

If you see the same denial repeatedly, don’t just fix each claim individually.

Ask:

Why does this keep happening?

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20. Create a Denial Dashboard

For example:

Now you can see where the real problem is.

If credentialing denials are costing you thousands of dollars, the solution isn’t simply hiring someone to appeal claims.

The solution may be fixing your credentialing process.

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21. Track Accounts Receivable

A practice can be profitable on paper and still have a cash-flow problem.

Track:

• Accounts receivable
• Days in A/R
• Aging
• Insurance balances
• Patient balances
• Denials
• Unpaid claims

Consider reviewing aging categories such as:

0–30 days

31–60 days

61–90 days

91–120 days

120+ days

The older an account becomes, the more attention it may require.

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22. Know Your Collection Rate

One of the most useful business metrics is your collection rate.

You want to know:

Of the revenue we are entitled to collect, how much are we actually collecting?

A practice with a high volume of claims but poor collections can look busy while losing money.

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23. Don’t Confuse Revenue With Profit

Suppose your practice collects:

$300,000

That sounds great.

But then you pay:

• Staff
• Rent
• Insurance
• Supplies
• Billing
• Software
• Taxes
• Professional services
• Marketing
• Equipment
• Other overhead

Your actual profit may be dramatically lower.

Revenue is not your paycheck.

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24. Understand Your Cost Per Birth

For birth practices, this can be a powerful metric.

Calculate the approximate cost associated with providing a birth service.

Consider:

• Supplies
• Mileage
• Equipment
• Backup
• Malpractice
• Administrative time
• Clinical time
• Postpartum care
• Billing costs
• Overhead

Then compare your actual reimbursement.

You may discover that a service that looks profitable isn’t nearly as profitable as you thought.

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25. Audit Your Own Charts

Don’t wait for a payer audit.

Perform periodic internal reviews.

Select a sample of charts and compare:

Documentation

with

Diagnosis codes

with

Procedure codes

with

Modifiers

with

Claim submission

with

Payment

Look for patterns.

Internal audits can identify problems before they become larger compliance or financial issues.

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26. Don’t Upcode

Upcoding means reporting a higher-level service than the documentation supports.

It’s not worth the risk.

A sustainable practice should never depend on:

“Let’s see if the insurance company pays it.”

Your billing should be based on:

What was provided.

What was documented.

What is appropriately coded.

What the payer allows.

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27. Don’t Unbundle Services

Another common compliance issue is reporting services separately when they are considered part of a larger service or package.

Whether services can be separately reported depends on the specific coding rules and payer requirements.

When in doubt, verify.

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28. Verify Eligibility

Insurance eligibility should be verified according to your practice’s workflow.

A patient having an insurance card doesn’t guarantee:

• Active coverage
• Correct plan
• In-network status
• Maternity coverage
• Coverage at your location

Eligibility verification can prevent avoidable surprises.

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29. Make Patient Financial Policies Clear

Patients should understand:

• Your fees
• Insurance participation
• Deposits
• Payment schedules
• Copays
• Deductibles
• Patient responsibility
• Refund policies
• Cancellation policies
• Financial assistance policies, if applicable

Financial conversations are much easier when expectations are established before care begins.

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30. Have a Billing Professional Review Your System

If billing isn’t your area of expertise, you don’t necessarily need to become a full-time coding expert.

But you do need to understand enough to manage your business.

Consider having an experienced medical coder, biller, compliance professional, or other appropriately qualified specialist review:

• Your claims
• Your coding
• Your documentation
• Your payer contracts
• Your denial patterns
• Your fee schedule
• Your workflow

This can uncover revenue leakage you didn’t know existed.

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The Midwife’s Billing Checklist

At minimum, ask yourself:

Credentialing

• Are all providers properly enrolled?
• Are NPIs correct?
• Are payer enrollments current?

Coding

• Are diagnosis codes accurate?
• Are CPT/HCPCS codes supported?
• Are modifiers appropriate?
• Is place of service correct?

Documentation

• Does the record support the claim?
• Is gestational age documented where relevant?
• Is trimester supported?
• Are services clearly documented?

Billing

• Are claims submitted promptly?
• Are denials tracked?
• Are claims followed up?
• Are patient balances managed appropriately?

Business

• What is our collection rate?
• What is our average reimbursement?
• What is our cost per client?
• What is our cost per birth?
• What is our actual profit?

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The Most Important Billing Tip for Midwives

Don’t treat billing as:

“The thing we send to insurance after we provide care.”

Treat it as part of your practice’s financial infrastructure.

Your clinical work creates value.

Your documentation communicates what you did.

Your coding translates that work into standardized language.

Your billing system communicates that information to the payer.

And your revenue keeps the practice operational.

When those pieces work together, the business becomes significantly stronger.

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Final Thoughts

Midwives are often taught how to provide excellent clinical care.

They aren’t always taught how to make sure that excellent care is accurately documented, appropriately coded, correctly billed, and fairly reimbursed.

That’s a business skill.

And learning it can make an enormous difference.

You don’t have to become a medical coding expert to be a successful midwifery business owner. But you should understand enough about billing and coding to know where your money is coming from, where it is being lost, and whether your systems are working.

The goal isn’t to bill more.

The goal is to accurately capture and collect the revenue your practice has legitimately earned.

Good billing isn’t about maximizing every claim.

It’s about building a compliant, accurate, efficient, and financially sustainable midwifery practice.

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