QUEST Integration - Maternity - Global Billing

Original Effective Date:
04/01/1999
Current Effective Date:
04/01/2019

A global maternity fee is paid for medically uncomplicated maternity cases, including all routine antepartum, delivery, and postpartum care provided by the same physician or provider group. The global fee includes payment of the initial prenatal visit and the routine follow up visit after delivery. Go to Payment Policies for more information on the Global Obstetrical Package policy.

Symptomatic Conditions of Pregnancy

The following conditions are not considered pregnancy but symptomatic as a result of pregnancy and may be paid separately in addition to the global fee:

• hypertension
• vaginitis
• urinary problems
• anemia
• diabetes

Non-Routine Medical Complications

The following complications are considered non-routine and payable separately from the global fee:

• pre or postpartum eclampsia/toxemia
• postpartum abscess and/or hematoma
• severe nausea of pregnancy requiring hospitalization
• unusual vaginal bleeding
• threatened abortion
• false labor requiring hospitalization

Claims Filing Information 

If the patient’s maternity care is divided among providers with one provider doing the delivery and another doing the antepartum and/or postpartum care, reimbursement is dependent on whether the same or different provider group renders the services, and whether claims are billed in sequence according to AMA CPT Manual and coding guidelines.

Evaluation and Management (E/M) services billed more than five months after an antepartum service, when the diagnosis indicates pregnancy or abortion, will be denied. If you treat a patient for a serious complication of pregnancy such as those listed above, or for a condition that is unrelated to the pregnancy, you may submit a claim for the services rendered.

Claims for complications must be submitted with the appropriate diagnosis code in order for payment to be made separate from the global fee.

Example 1

Physician performs routine obstetric service.

Diagnosis: Pregnancy - single, routine, without sickness (Z33.1)

Claim contains:
59400 - Routine obstetric care (including prenatal care, vaginal delivery and postpartum care)
81005 - Urinalysis

QUEST Integration will:
Pay a global maternity fee.  Urinalysis is considered an integral part of a prenatal visit and is included in the global fee.

Example 2

Patient is diagnosed with toxemia during a scheduled prenatal visit.

Diagnosis: Toxemia (O15.02)

Claim contains:
99212 - Office visit

QUEST Integration will:
Pay the visit separately from the global fee.

Billing for Multiple Gestation Deliveries

When billing the global maternity fee for multiple gestation deliveries, please use the appropriate CPT code for vaginal or cesarean delivery and add modifier -22. The diagnosis indicated in block 21 of the CMS 1500 claim form should reflect the multiple birth and a comment should appear in block 19 (e.g., twins or triplets).

Revision History