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SHPBN-2017-019 OB Care Billing Instructions

Date: 06/01/17

Clarification of KMAP Billing Guidelines

The following guidelines must be followed to avoid claim denials when billing for obstetrical services:

  • One to three prenatal visits – Bill using E&M office visit codes 
  • Four to six prenatal visits only – Bill using code 59425
  • 7 or more antepartum care visits only – Bill using code 59426
  • Delivery only - Bill using code 59409 or 59514
  • Delivery and postpartum care only - Bill using code 59410 or 59515
  • Postpartum care only - Bill using code 59430
  • Four to six antepartum care visits, delivery & postpartum care only - Bill using codes 59425 and 59410 or 59515
  • Total OB care; seven or more antepartum care visits, delivery and postpartum care - Bill using codes 59400 or 59510

Billing for ARNPs and PAs and Limitations

  • If an ARNP or PA provides part of the prenatal care but does not deliver the baby, the physician may bill the global fee without indicating the PA or ARNP as the performing provider
  • If the ARNP or PA provides part of the prenatal care and delivers the baby, the services must be broken out and the PA or ARNP indicated as the performing provider. Providers should not bill for OB services until care is completed (for example, the beneficiary delivers or the beneficiary is no longer a patient)
  • Codes 59425 and 59426 may be billed only once per provider, per beneficiary pregnancy. These codes must not be billed together by the same provider for the same beneficiary, during the same pregnancy
  • Pregnancy-related (E&M) office visits must not be billed in conjunction with code 59425 or 59426 by the same provider for the same beneficiary, during the same pregnancy
  • Code 59426 is limited to one per pregnancy, per provider

Billing for RHCs & FQHCs

  • No “bundled” codes are allowed for RHC/FQHC billing under KanCare. Traditionally “bundled” obstetrical (OB) services, such as routine OB care, should be “unbundled” and billed separately on per encounter basis
  • Prenatal visits and postnatal visits can be billed by the clinic/center using the appropriate E&M office visit codes, whereas other unbundled components of “bundled” services should not be billed under the RHC/FQHC provider number unless the services are furnished in an “approved” setting
  • When furnished in a nonapproved setting, such as a hospital, these services can be billed under the practitioner’s provider number using separate CPT codes for unbundled services

If you have questions about this bulletin or other provider resources, please contact Customer Service at 1-877-644-4623.