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Please notify PHP of all multiple births and high risk pregnancies by calling PHP Medical Management at (260) 432-6690 or (800) 982-6257, ext. 12. For prior authorization needs, please contact PHP's vendor partner Vālenz Health via fax at 863-333-4417. The following guidelines are associated with maternity claims submission:
GLOBAL MATERNITY SERVICES
Services provided in uncomplicated maternity cases include antepartum care, delivery and postpartum care.
Antepartum Care includes:
- physical examinations
- initial and subsequent history
- blood pressure
- recording weight
- routine chemical urinalysis
- fetal heart tones
- monthly visits up to 28 weeks gestation
- biweekly visits up to 36 weeks gestation
- weekly visits until delivery
Delivery Services include:
- hospital admission
- admission history and physical examination
- induction of labor
- management of uncomplicated labor
- vaginal delivery (with or without episiotomy or forceps)
- cesarean delivery
Postpartum Care includes:
hospital and office visits following vaginal or cesarean delivery
GLOBAL CODES
- 59400 Routine obstetric care including antepartum care vaginal delivery and postpartum care.
- 59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care.
- 59610 Routine obstetric care including antepartum care, vaginal delivery and postpartum care after a previous cesarean delivery. (VBAC)
- 59618 Routine obstetric care including antepartum care, cesarean and postpartum care following attempted vaginal delivery after previous cesarean delivery.
ANTEPARTUM CARE ONLY
Antepartum or prenatal care includes the initial and subsequent histories, physical examinations, recording of weight, blood pressures, fetal heart tones, and routine chemical urinalysis.
- 59425 Antepartum care only, 4 - 6 visits.
- 59426 Antepartum care only, 7 or more visits.
Although these codes are intended to indicate a certain number of visits, PHP is set up to pay these codes per occurrence. When you submit claims for Antepartum care alone, be sure to indicate the specific date and number of times you saw the patient. This will assure proper payment.
BREAK-OUT SERVICES
Break-out of services is required when a PHP member:
- has more than one physician or physician group providing services during her maternity care
- change in insurance plan during her pregnancy
- has miscarried
The individual codes listed below are to be used when breaking out services:
- E/M code 1-3 OB visits CPT 59425 4-6 OB visits*
- CPT 59426 7 or more OB visits*
- CPT 59410 Uncomplicated vaginal delivery including postpartum care
- CPT 59515 Uncomplicated cesarean delivery including postpartum care
- CPT 59409 Vaginal delivery only
- CPT 59514 Cesarean delivery only
- CPT 59430 Post Partum care only *
The individual office visit codes require a range of service dates. The number of units in box F should indicate the number of visits in the range and include all services as outlined in "Antepartum Care.”
MULTIPLE BIRTH DELIVERIES
Contact PHP for assistance in correct coding of multiple birth deliveries
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