Billing for Care after the Initial Outpatient Postpartum Visit: The Fourth Trimester
The American Rescue Plan Act, signed into law on March 11, 2021, makes available a new pathway states can use to extend Medicaid coverage for pregnant people to one year postpartum. This pathway—known as a state plan amendment (SPA)—will become effective next year (April 1, 2022).
These coverage changes have implications for medical billing and coding. The current mechanisms to bill for obstetric care include billing each office visit as an appropriate Evaluation & Management (E/M) service and billing the delivery CPT codes (59409, 59514, 59612, 59620), or utilizing the global maternity codes.
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After the initial postpartum period (no later than 12 weeks after birth) care should not be covered by the global maternity codes but should be billed using the appropriate E/M or procedure codes.
Postpartum Components of the Global Maternity Codes
(59400, 59510, 59610, 59618)
- Routine hospital visits
- Vaginal Delivery – 1 inpatient visit, 1 discharge; codes 99231, 99238
- Cesarean Delivery – 2 inpatient visits, 1 discharge; codes 99231, 99232, 99238
- Routine office visits during the postpartum period
- Vaginal Delivery – 1 office visit, valued as code 99214
- Cesarean Delivery – 2 office visits, 1 valued as code 99213 and 1 valued as code 99214
- The comprehensive postpartum office visit (99214) should include:
- An interval history
- Physical examination and Pap test, if needed
- Review or initiation of birth control methods
- Discussion including breastfeeding, emotional status, counseling for future pregnancies, and any lab studies or immunizations appropriate for the specific patient
- Postpartum counseling for conditions that occurred during pregnancy
Evaluation and Management Codes
Code Description Time
99202
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
99211
Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
(N/A)
99212
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
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When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.
Note: For services 55 minutes or longer, see Prolonged Services 99417
Other Related Services
- IUD placement performed at a problem visit would be reported with CPT code 58300 (Insertion of intrauterine device (IUD) linked to ICD-10-CM code Z30.430 (Encounter for insertion of intrauterine contraceptive device). The E/M service would have modifier 25 added to indicate that a significant separately identifiable E/M service was performed in addition to the level of E/M service valued into the procedure performed.
- A well-woman visit at three months postpartum (at least one calendar year from the last annual well-woman service performed and billed) may be reported using CPT codes 99394-99397, as appropriate.
- If care must be transferred to a different specialty, Transitional Care Management codes (99495-99496) may potentially be reported for the coordination of care with providers from other specialties if the components of these codes are performed and documented.
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