Coding for Postpartum Services (The Fourth Trimester)
ACOG has received many requests for coding recommendations in response to the publication of the Committee Opinion 736: Optimizing Postpartum Care. This document provides clinical and educational guidelines and other resources to improve care for women and infants during the postpartum period.
Currently, payers and others are attempting to understand the ramifications of the new postpartum care paradigm. There may be an effort to develop payer trials to evaluate the efficiency and efficacy of the new care model. In the meantime, coding for postpartum services should be reported as follows.
Components of the Global Package
These postpartum services are currently included and valued into the global obstetrics package for codes 59400 and 59510.
- Routine hospital visits
- Vaginal delivery; one inpatient visit, one discharge; codes 99231, 99238
- Cesarean delivery; two inpatient visits, one discharge; codes 99231, 99232, 99238
- Routine office visits during the postpartum period
- Vaginal delivery; one office visit, valued as code 99214
- Cesarean delivery; two office visits, one valued as code 99213 and one 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
- Discussions on 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 (ie, glucose tolerance testing in GDM, counseling for stillbirth)
- Additional visits for “uncomplicated” postpartum care is considered to be included in the global obstetrics package.
Note: Evaluation and management (E/M) code 99214 includes in its value, 25 minutes of physician time spent face-to-face with the patient.
Services That Are Separately Reportable during the Postpartum Period
- Treatment and management of complications requiring other services or visits during the postpartum period (eg, GDM, hypertension in pregnancy, preterm birth). As an example, ordering the two-hour OGTT for a woman with GDM would be included as part of postpartum care. However, evaluating the patient and initiating treatment of newly-diagnosed Type 2 diabetes with metformin would be a separately reportable service.
- Management of problems unrelated to the pregnancy (eg, hypertension, glucose intolerance, obesity)
Coding for Problem Visits during the Postpartum Period
- Select an appropriate Current Procedural Terminology (CPT) E/M code (eg, 99211-99215), based on the service(s) performed and documented to assess and manage the problem(s) or complication(s). Append modifier 24 to the E/M code. Modifier 24 indicates that the E/M service for the problem is unrelated to typical postpartum care by the same physician during a global period.
- Link the E/M code to an International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) code that provides the medical necessity for performing the service.
- Report any procedures performed with the appropriate CPT code linked to the ICD-10-CM code that describes the medical necessity. If both an E/M service and a procedure are performed during the same session, append modifier 25 to the E/M service. Modifier 25 indicates that a significant, separately identifiable E/M service was performed by the same physician or other qualified health care professional on the same day of the procedure. For example, an 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.
- If patients continue to have problems or issues, visits to address those issues would be reported as problem visits with E/M codes linked to the diagnosis code for the issue or problem.
Coding for Complications or Adverse Pregnancy Outcomes during the Postpartum Period
- Hypertension, gestational diabetes, or other pregnancy complications are risk factors for future chronic disease. The first postpartum visit (99214, a 25-minute visit), is valued into the global. Visits for complications may be billed outside the global. 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.
- Visits for complications/adverse pregnancy outcomes are coded as problem visits reported with codes 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of the three key components: history; examination; and medical decision making. Counseling or coordination of care with other physicians, other qualified health care professionals, or agencies…). The E/M code selected is based on the level of service provided and linked to a diagnosis for the issue being managed.
- 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.
- If there is a medically necessary reason for specific tests, those tests may be reported. Typically, the physician is ordering but not performing the test, so, the diagnosis code to report on the lab request will be the reason the test was ordered (eg, glucose tolerance, lipid panel).
Payers Who Do Not Reimburse the Global OB Package
Some payers do not reimburse for global obstetrics package codes. You should contact these payers to determine how they want these services reported in order to avoid claim denials and ensure appropriate reimbursement for the services provided.
Learn more in the ACOG Postpartum Tool kit.