New Maternity Billing Codes Better Reflect Modern Care, Ob/Gyns Say

Maternity care billing is getting an overhaul that ob/gyns say is long overdue and will likely improve patient care and physician compensation — as long as it’s rolled out effectively.

For decades, there’s been a global system for pregnancy care billing in which all patients got the same package of 13 visits and clinicians were paid in a lump sum for this bundle. But starting Jan. 1, ob/gyns can individualize patients’ care plans and bill for specific services thanks to new maternity billing codes adopted by the American Medical Association (AMA).

Clinicians currently bill the same global bundle of services for all obstetric patients regardless of insurance type, similar to the billing approach used in some surgeries. Soon, ob/gyns will input new Current Procedural Terminology (CPT) codes for the specific services, visits, and add-ons that their patients need, as most other clinicians do for other types of care.

The long-used bundled package included prenatal care, labor and delivery care, and one postpartum visit. Maternal morbidity and mortality often occurs in the postpartum period, and ob/gyns now recommend that patients have more than one postpartum visit to keep tabs on their well-being.

This change comes after years of advocacy from ob/gyns and groups like the American College of Obstetricians and Gynecologists (ACOG) who argued that the bundled payment structure in place since the 1990s doesn’t reflect the needs of modern maternity care.

“The unbundling of the obstetric codes has been long overdue and will finally offer relief to so many ob/gyns who viewed the global obstetric payment as a major pain point,” said Steven Fleischman, MD, MBA, immediate past president of ACOG, in a press release.

Nikki Zite, MD, MPH, an ob/gyn at the University of Tennessee Medical Center in Knoxville, told MedPage Today that an ACOG member survey found that ob/gyns thought “the ‘global billing’ for pregnancy care was a major barrier to individualized care and practices’ financial stability.”

Tani Malhotra, MD, a maternal-fetal medicine specialist in Cleveland, said that the new billing will change the timeliness with which doctors are paid.

“With bundled payments, you get reimbursed at the end of the obstetric episode … [but] now it’ll be a more fee-for-service structure, so you’ll get … the same reimbursement interval as you would with other services that are provided,” she told MedPage Today.

Individualized care will also benefit patients, she noted, as patients today have more health conditions, such as hypertension and diabetes.

“Maternity care in the United States is totally different than what it was 30 years ago,” she said, pointing out that the new billing structure better values and compensates obstetricians for their work.

Melissa Simon, MD, MPH, an ob/gyn at Northwestern Medicine in Chicago and director of the university’s ELEVATE Lab, told MedPage Today that the bundled one-size-fits-all approach doesn’t make sense for obstetric care. For instance, some patients need more in-person visits to meet their health needs, while some rural patients may prefer remote visits when appropriate. Flexible billing will also allow clinicians to align patient care with evolving clinical guidelines.

“These new codes create opportunities for more tailored and appropriately paid care,” Simon noted, adding that this level of granularity will also allow for better data collection and analysis, which can further improve care provision.

However, she said there’s still a lot of unknowns about how the new codes will affect patients’ pocketbooks and it’s not yet known what the reimbursements will be for the new codes.

“Whenever you shift to a la carte billing, that could make pregnancy care and postpartum care pricier in some cases,” she said. “It really is going to depend on how insurers, both commercial and public, classify visits, apply deductibles or copays, and how they classify non-preventive versus preventive services.”

At the end of the day, Simon said that the way the new system is implemented is vital, and something that ob/gyns will be paying close attention to.

CMS included the new AMA obstetric codes in the 2027 Medicare Physician Fee Schedule proposed rule. In a statement, ACOG President Camille Clare, MD, MPH, commended CMS for this move and for increasing the proposed value for these codes.

However, Clare said that ACOG is concerned that CMS is also considering making new codes to reflect the current global coding system, which “would cause even greater disruption and confusion by increasing administrative burden for obstetric clinicians and practices and forcing them to learn and operate under two separate billing structures,” which could worsen obstetric care disparities.

The new CPT codes are not without critics. Rep. Earl “Buddy” Carter (R-Ga.) wrote a letter to the AMA president, pointing to his concerns that the new system could result in unnecessary visits and tests to get more reimbursements.

However, Malhotra pushed back on this argument.

“All we’re asking is just reimburse us for the work we’re doing. We’re not trying to game the system,” she said.