Prenatal care billing
Prenatal care, individual visits (3 or fewer)
Conditions that may necessitate itemization of services are:
- Irregular or late prenatal care
- Member experiences a miscarriage or terminates pregnancy
- Member changes OB provider
- Member changes insurance company
Billing instructions:
- Bill all visits at the end of the treatment period, which may be defined by one of the reasons listed above.
- Code: Use an appropriate level of Evaluation and Management (E&M) code
- From/To dates (Box 24A HCFA 1500): List date of service on each line for each E & M code billed
- Quantity (Box 24G HCFA 1500): Indicate unit of 1 for each E&M code billed. Total number of lines should not exceed 3.
- Fill in the EXACT LMP date in box 14 of the HCFA 1500.
- Other considerations apply when a patient is treated for an illness
Prenatal services only (no delivery associated with the visits)
Bill the global prenatal service package code at the end of the treatment period, not separately at every visit.
- Codes: Use 59425 to bill 4 to 6 visits, 59426 to bill 7 or more visits
- From/To dates (Box 24A HCFA 1500): Indicate first prenatal visit and last prenatal visit
- Quantity (Box 24G HCFA 1500): One
- Fill in the EXACT LMP date in box 14 of the HCFA 1500.
- Other considerations apply when a patient is treated for an illness
Prenatal package with delivery and postpartum care (7 or more prenatal visits)
Bill global package after the post-partum visit.
- Codes: Use 59400, 59510, 59610, and 59618
- From/To dates (Box 24A HCFA 1500): Indicate first prenatal visit and delivery date
- Quantity (Box 24G HCFA 1500): One
- Place of service: inpatient
- Fill in the EXACT LMP date in box 14 of the HCFA 1500.
- Other considerations apply when a patient is treated for an illness
High-risk pregnancies
When a high-risk prenatal condition exists, you may perform additional services that fall outside of the normal prenatal package.
- For high-risk pregnancy visits that exceed the average number of normal prenatal visits, report the E&M service. These additional visits should only be reported when required outside of the normal schedule of prenatal visits and the services were to monitor or treat the high-risk condition.
- The diagnosis must be for the high-risk condition and the documentation must represent the ongoing concern.
Visits for illness during prenatal period
When a patient is treated incidentally for a problem unrelated to her prenatal care on the same date as the prenatal visit, include the visit as part of routine prenatal care. Copayment will apply to the prenatal maximum.
If an office visit for an illness is scheduled outside of the planned interval for prenatal care:
- Take the regular office visit copayment (does not apply to prenatal maximum)
- Documentation for E&M services billed for "sick" diagnosis should be complete and separate from the OB record
- Bill the appropriate E&M code for the illness presented and care rendered
- List the illness diagnosis code as primary
- Submit bill at the time of service
- Do not include in listing of prenatal visits when billing the OB package code
