Midwife Billing Maternity Care: What is and isn’t included?

Midwife Billing Maternity Care: What is and isn’t included?

Global Maternity 

Global maternity care includes prenatal care, birth, and postpartum care for a woman if you assist her entire pregnancy. If she transfers out due to risk or moves, 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 woman.

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? Can I bill lab draws, urine analysis, wet mounts, tobacco counseling, and risk assessment screenings? Home visits during care, can I bill them as well?

Maternity Care

What is global maternity?  

Think of maternity care as a “routine service” part of traditional pregnancy care. Prenatal visits are standard with global maternity care. The 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.

The first prenatal visit can be billed to some insurance companies if the pregnancy test is performed (code for the urine pregnancy test is 81025) and the diagnosis code confirmation of pregnancy is used. Then the first visit can be billed as either 99205 or 99215, depending on if the patient is established or new to the practice.

There are a couple of 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 of billing and coding rules. Even if there are national guidelines for coding, each private insurance company will make up its own rules on how it wants claims to be submitted and codes to be used.

Why insurance billing is so complicated

There are many rules, and they are constantly changing. If a woman 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 the level of care (levels 1–5 based on time spent with the patient and complexity of visit). 

If she is seen for primary care concerns the same day as her prenatal visit, add a modifier 25 to the end of the office visit code to signify to the insurance company that there were two distinctly separate services offered on 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 who can’t drive into the office for visits, not based on the 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 visits are 99346–99350, depending on the time spent with the patient.

How to avoid overhead cost

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 the items on the list were home visits, birth assistance, birth supplies, driving distance fees to home for those who lived more than 30 miles from the office, and administration fees to help cover insurance billing administration costs.

Many families willingly paid for these aspects of care, as the remainder of their care was usually included in their insurance plan. Consequently, the overall out-of-pocket expenses for my services were significantly lower than other home birth midwives in my vicinity.

Any testing done that is part of routine prenatal care is included in the global code (urine analysis for protein and glucose is standard of care). If she has signs of vaginal infection and a wet mount read is warranted, code 83986 can definitely be billed in addition to care. Lab draws within the office are code 36415 and billed separately.

Global maternity care 

Prenatal care is divided only when the patient transfers care. The code utilized is determined by the number of visits the patient has had with the practice. If the patient has had less than 4 visits and is new to the practice, each individual visit is billed as a provider office visit 99201-99205 for initial prenatal care.

Typically, I would bill 99205 as I spend 60–90 minutes with the patient and ensure that my charting notes reflect the total time spent. Subsequent visits are coded as 99213–99215, depending on the duration of time spent with the patient.

If the patient is already established with the practice (seen within the past 3 years), then codes 99211-99215 would be used. The remaining prenatal visits are usually billed as 99213 or 99214. If the patient has been seen 4-6 times by the practice (which may involve multiple midwives within the office), the code used would be 59425. For seven or more prenatal visits, the code would be 59426.

In the event that a patient transfers into our practice after receiving care at another office, it is necessary to separate the global maternity care codes based on the services directly provided by our team. This includes prenatal care visits, birth, and postpartum care. The code for vaginal delivery is 59409. The code for vaginal delivery and postpartum care combined is 59410. The code for postpartum care only is 59430.

Prolonged support

Prolonged one one-on-one support during labor by midwives is paid by some insurance companies. Prolonged support is based on routine care offered in the 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 the patient entire time until baby is born. If a medical complication for a 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 a separate service from vaginal delivery. 

Home visits for home birth are sometimes paid. Learn each insurance company’s specific policies for codes really well. Have lots of notes (perks of having a biller within the office to learn all these nuances).

Birthtub rentals were rarely paid for by insurance companies. The code is 97113 for tub rental itself and then 97036 for whirlpool therapy during labor. Aetna and United Health would sometimes pay for 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 detail of your specific needs and help maximize reimbursement for your practice. Don’t miss revenue for the care you are providing!