Maternity services: Prenatal, delivery and postpartum
Applies to members of:
All plans, except self-funded plans with a Maternity exclusion for dependents
Routine maternity services coverage
Routine maternity services are not synonymous with preventive benefit with no cost share. Consult plan documents for specific routine maternity benefits.
Self-funded plans with a Maternity exclusion for dependents will deny all services except routine lab work.
Clinical edit: Obstetric Services, Global Care
Claims will deny Evaluation and Management services (99202-99215) when billed with a diagnosis of post-partum care uncomplicated postpartum care (ICD-10 codes Z39-Z39.2), contraceptive management (ICD-10 codes Z30.011, Z30.013-Z30.09), or family planning advice when a delivery care only service (59409, 59514, 59612, 59620) has been billed in the past 42 days (6 weeks) by any provider.
AMA CPT manual instructs postpartum care cannot be reported as a separate E/M service during the postpartum period, whether performed by the same provider who performed the delivery or by a different provider. Postpartum care is correctly reported.
For both professional and facility claims, claims will be denied when a delivery procedure code is billed and an outcome of delivery diagnosis isn't also reported on the claim. This is in accordance with Chapter 15 of the ICD-10 official coding and reporting guidelines.