The following guidelines apply to claims for obstetrical delivery and associated services:

1. The delivery of a viable infant at any time, regardless of the period of gestation, should be paid as a delivery.
   
   
2. Interruption of pregnancy after 24 weeks should be processed as a delivery.
   
   
3. Attendance at labor (59899) by the same physician who performs the delivery is considered part of the global delivery fee and is not separately payable.  A participating, preferred, or network provider cannot bill the member for this service.
   
   
4. The following services are considered an integral part of a vaginal delivery (59400-59410) or a cesarean section (59510-59515), or delivery after previous cesarean delivery (59610-59622). They are not eligible as distinct and separate services.
   
   
   1. Induction of labor (e.g., PEGGELL insertion, use of pitocin)
   2. Augmentation of labor (e.g., use of pitocin)
   3. Removal of shirodkar sutures prior to delivery
      
      • under anesthesia (except local) (59871)
      • under local anesthesia or without anesthesia
   4. Methods used to alter presentation of the fetus such as internal rotation, use of forceps, etc.

      NOTE: Separate payment may be made for external version (59412).

   5. Suturing of episiotomy
   6. Fetal scalp blood sampling (59030)
   7. Fetal monitoring, including insertion of fetal oximetry sensor (0021T)
      
      

   If any of the services listed above are reported on the same day as obstetrical delivery, and the charges are itemized, combine the charges and pay only the delivery.  Payment for the obstetrical delivery performed on the same date of service includes the allowance for the services listed above in item #4.  A participating, preferred, or network provider cannot bill the member separately for any of those services in this case.

   If the above listed integral services (Item #4) are performed independently, process them under the appropriate code(s).

5. When resuturing of an episiotomy is required because of complications following a delivery, the case should be referred for medical review.
   
   
6. Fetal Testing
   1. Payment should be made for fetal non-stress testing (59025) or fetal contraction stress testing (59020) as distinct and separate services from the global obstetrical allowance.
   2. The fetal non-stress test does not require the use of a pharmacologic agent. The contraction stress test requires the use of a pharmacologic agent (e.g., oxytocin) and is generally administered intravenously. These tests are used to determine fetal status and viability.
      
      
7. Payment for obstetrical care (59400 and 59410) includes payment for vaginal delivery of the infant and delivery of the placenta. However, if the obstetrician is not present for the delivery (e.g., the infant is delivered en route to the hospital), payment can be made to the attending obstetrician for the delivery of the placenta (59414), as well as for antepartum care (59425, 59426) and/or postpartum care (59430), as appropriate.
   
   
8. The following guidelines apply to payment for multiple births:
   • If the infants are delivered by the same or different methods (vaginal or cesarean section), payment should be made for one delivery for each newborn.
   • Antepartum and postpartum care should be included with only one delivery code (i.e., reimbursement will be made only for a single antepartum and postpartum period, regardless of the number of newborns delivered).
     
     
9. Payment for the delivery or total obstetrical care includes the allowance for fetal monitoring during labor.  However, separate payment may be made for fetal monitoring to a physician other than the attending physician (code 59050 or 59051) when any one of the following criteria is met:

• For any high risk pregnancy
• For multiple gestations with complications
• For any unusual or abnormal fetal heart rate findings
• When there is a need for scalp ph
• For fetal decelerations which are recurrent and of unknown etiology
• When there are atypical fetal responses with maternal medical diseases
• When there is a pattern indicating fetal distress and the possible need for a cesarean section.      

NOTE:

When fetal monitoring (59050 or 59051) is provided on the same day as a consultation by the same health care professional, the fetal monitoring is not eligible for separate payment. When fetal monitoring is a benefit, the fetal monitoring is included in the allowance for the consultation, and therefore, is not separately billable by participating, preferred, or network providers.

If there are unusual circumstances (e.g., as in obstetrical care for high risk pregnancies), the claim for the global obstetrical care may be given individual consideration.  Additional payment for such care will be made when warranted by the patient’s medical condition, based on documentation in the patient’s medical record.  In order to facilitate the processing of claims for high risk obstetrical care, the appropriate global obstetrical care code should be reported with a 22 modifier.  The charge for additional payment above the global obstetrical fee should reflect the additional medical care provided.  Additional medical visits should not be itemized on the claim.  However, the additional visits should be documented within the patient’s medical record.  All pertinent records should be attached to the claim form.

For guidelines concerning obstetrical ultrasound studies, see Medical Policy Bulletin X-17.

For guidelines concerning anesthesia and delivery by the same physician, see Medical Policy Bulletin A-2.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

If the integral services listed in item #4 are reported on the same day as the delivery, and the charges are itemized, combine the charges and pay only the delivery. However, if the integral service is reported independently, process it for payment under the appropriate procedure code.

PRN References

06/1994, Vaginal repair following delivery, reimbursement of
03/1995, Fetal monitoring, codes and reimbursement for
02/1996, Reporting high-risk obstetrical care
10/1996, Procedure coding for vaginal births after cesarean
04/1997, Vaginal birth after cesarean (VBAC) delivery, codes and reimbursement of
06/1997, External cephalic version, code and reimbursement of
12/2000, Guidelines clarified for delivery and attendance at delivery of multiple births
06/2003, External version now covered
06/2003, How to report antepartum care
08/2005, Attendance at labor coverage guidelines clarified