Midwife Billing Maternity Care: What is and isn’t included?
Global maternity care includes prenatal care, birth, and postpartum care for a women if you assist her entire pregnancy. If she transfers out due to risk or moving, billing codes are broken up based on services rendered. There are codes for individual prenatal visits, multiple prenatal visits, birth directly, and postpartum care only. The codes billed would be applicable to the care provided to that women.
If a woman has a cold and is treated, can I bill for seeing her outside of global maternity care? Her first visit with office, can I bill that separately as confirmation of pregnancy or is it part of global care coding? Lab draws, urine analysis, wet mounts, tobacco counseling, and risk assessment screenings, can I bill them? Home visits during care, can I bill them as well?
There is so much to think about and I will answer each of the scenarios above in time. Think of maternity care as “routine services” part of traditional pregnancy care. Prenatal visits are standard with global maternity care. Only way you can bill them separately is if she transfers care so then each care provider can both be paid for their part of her care.
First prenatal visit can be billed to some insurance companies if pregnancy test is performed (code for urine pregnancy test is 81025) and diagnosis code confirmation of pregnancy is used. Then first visit can be billed as either 99205 or 99215 depending on if patient is established or new with practice.
There are a couple insurance companies that require you to break up the global code into prenatal care, birth, and postpartum care (Blue Care Network in our area). That is the most challenging part about billing and coding rules. Even if there are national guidelines for coding, each private insurance company will make up their own rules on how they want claims to be submitted and codes to be used.
That is mainly why insurance billing is so complicated. There are many rules and they are constantly changing. If a women comes to your office for something outside of routine prenatal care like a cold or ear infection, that is billed as an office visit based on level of care (level 1 to 5 based on time spent with patient and complexity of visit). If she is seen for primary care concerns same day as her prenatal visit, add a modifier 25 to end of office visit code to signify to the insurance company there were two distinctly separately services offered in the same day.
Home visits are not part of routine care in the medical system of the United States, but most insurance companies will pay for this service. Be careful though, because it is technically designated for home bound patients that can’t drive into the office for visits, not based on patient or midwife’s convenience to see the patient in their home. Use the accurate diagnosis code of pregnancy on the claim and the insurance company will decide if it will be reimbursed or not.
I believe that a 36 week gestation home visit, prepping for home birth, looking over supplies, and giving the midwife a “dry run” to the home prior to birth is essential. Insurance companies may not feel the same way. Codes for home visit are 99346-99350 depending on time spent with patient.
How I avoided the additional overhead cost, without knowing if insurance would pay for the home visit, was to make sure my financial agreement with families clearly stated what could be an additional, non-covered service by insurance plans and would be the patient’s ultimate responsibility. Among list included home visits, birth assistant, birth supplies, driving distance fee to home, for those who lived more than 30 miles from office, and administration fee to help cover insurance billing administration costs.
Many families were more than happy to pay for these aspects of care since the rest of their care was typically covered by the insurance plan. This made overall out of pocket costs for my care a fraction of other home birth midwives in my area.
Any testing done that is part of routine prenatal care is included in global code (urine analysis for protein and glucose is standard of care). If she has signs of vaginal infection and wet mount read is warranted, code 83986 can definitely be billed in addition to care. Lab draws within office are code 36415 and billed separately.
Global maternity care is code 59400. Prenatal care is broken up only if patient transfers care. The code used would be based on how many visits a patient was seen by a practice. If the patient was seen less than 4 times and new to practice, then each individual visit is billed as provider office visit 99201-99205 for initial prenatal care. I would usually bill 99205, because I spent 60-90 minutes with the patient and made sure my charting notes had that total time noted. Subsequent visits are coded 99213-99215 depending on time spend with patient.
If a patient is already established with the practice (seen less than 3yrs ago), then code 99211-99215 would be used. Rest of prenatal visits were usually billed as 99213 or 99214. If seen 4-6 times by practice (can be multiple midwives within office), code would be 59425. Seven or more prenatal visits was code 59426.
If transferred into our practice after already establishing care at another office, you need to break up global maternity care codes into what services your team directly provided. Prenatal care visits, birth, and postpartum care. Vaginal delivery code is 59409. Vaginal delivery and postpartum care code together is 59410. Postpartum care only code is 59430.
Prolonged one on one support during labor by midwife is paid by some insurance companies. Prolonged support is based on routine care offered in medical system. The vaginal delivery code allots for around 2 hours of provider time at the bedside and checking on the patient while nurse does most of the labor support. With out of hospital births, midwife is the labor support and is with patient entire time until baby is born. If a medical complication for mother occurs during labor, it is very easy to get this code paid.
If it is a normal vaginal delivery, rarely do insurance companies pay this prolonged support code 99291,25 and 99291,25 (prolonged support first hour and each 30 minute increment after that). Modifier 25 shows it was separate service from vaginal delivery. Home visits for home birth are sometimes paid. Learn each insurance companies specific policies for codes really well. Have lots of notes (perks of having a biller within the office to learn all these nuances).
Birth tub rentals were rarely paid by insurance company. Code is 97113 for tub rental itself and then 97036 for whirlpool therapy during labor. Aetna and United Health would sometimes pay these codes. Otherwise, families paid cash for tub rental of $150 from practice directly.
Learning billing and coding can be done, but it takes time and really is all about keeping up with ever changing guidelines and rules. With my consultation services, I can go into details of your specific needs and help maximize reimbursement for your practice. Don’t miss revenue for care you are providing!