CPT code 59400 is one of the most frequently used global codes for maternity care. Yet many billers get it wrong. The reason? Complex documentation and bundling/unbundling of services. Healthcare providers must bill this code correctly. Otherwise, they will face claim denials and lose a lot of revenue.
That’s why our experts at NeuraBill have compiled this comprehensive guide on CPT code 59400. So, let’s start.
CPT Code 59400 – Description
CPT code 59400 is known as a “global code” in medical billing. Unlike other CPT codes that represent a specific service or procedure, 59400 represents an entire set of services provided in a specified timeframe. So, what exactly is it?
According to the official American Medical Association (AMA) definition, CPT code 59400 is defined as:
“Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps), and postpartum care.”
It bundles routine obstetric care into one package, including antepartum care (prenatal visits), vaginal delivery (with or without an episiotomy or forceps), and postpartum care (follow-up after birth). Like all other global codes, the purpose of this code is to simplify billing for OBGYNs by covering the full journey of an uncomplicated pregnancy under one provider or practice.
The following services are included in each of the components:
Antepartum Care
- Initial and subsequent history and physical examinations
- Recording of weight, blood pressure, and fetal heart tones
- Routine chemical urinalysis (CPT codes 81000 and 81002)
- Approximately 13 visits for uncomplicated cases, typically following this schedule:
- Monthly visits up to 28 weeks of gestation
- Biweekly visits from 28 to 36 weeks of gestation
- Weekly visits from 36 weeks until delivery
Vaginal Delivery
- Admission to the hospital, including history and physical exams
- Management of uncomplicated labor
- Vaginal delivery (with or without episiotomy, with or without forceps)
- Delivery of the placenta
- Administration/induction of intravenous oxytocin
- Repair of first or second-degree lacerations
Postpartum Care
- Uncomplicated inpatient visits following delivery
- Routine outpatient E/M services provided within 6 weeks of delivery
- Discussion of contraception
Please note that it is essential that the patient continues to get the treatment from a single healthcare provider. If a patient changes providers during pregnancy, CPT code 59400 is not applicable.
Appropriate Use Cases for CPT Code 59400
So, when should you use CPT code 59400? To better understand the practical usage of this code, let’s look at some real-world scenarios in which healthcare providers can use this code.
Single Gestation
CPT code 59400 should only be used for one baby. If the patient is having twins or triplets, you will need additional codes to reflect the extra work involved in multiple births.
Pregnancy without Complications
All the services provided under CPT code 59400 must be rendered if there are no complications in the pregnancy. This code is intended for routine vaginal deliveries, which may include episiotomy and/or forceps, but do not involve cesarean section.
Modifiers to Append with CPT Code 59400
The following modifiers may be appended to code 59400, when needed, to enhance coding specificity.
| Modifier | Description | Application in Delivery Context |
|---|---|---|
| 22 | Increased Procedural Services | Used when delivery requires extra effort, e.g., labor lasts 20 hours or complications demand more work beyond the standard procedure. |
| 52 | Reduced Services | Applied if the complete service package is not provided, e.g., another physician handled prenatal care, and you only performed the delivery. |
| 59 | Distinct Procedural Service | Used for a separate, non-routine procedure on delivery day, e.g., repairing a laceration not included in the global package (59400). |
Applying the correct modifiers is essential. Using the wrong modifiers will result in a claim denial. In addition to the modifiers that we discussed above, the following are some important modifier usage considerations for CPT code 59400:
- For third- and fourth-degree laceration repair, append modifier 22 to the global OB code (59400) with appropriate documentation supporting the increased complexity of the service.
- For high-risk pregnancies requiring additional visits beyond the typical 13, append modifier 25 to the E/M codes for those visits with appropriate high-risk diagnosis codes.
Reimbursement Guidelines for CPT Code 59400
Paying attention to the following guidelines while billing code 59400 will help you avoid erroneous claim submissions and resulting denials.
Follow the Billing Requirements
Filing a claim with CPT code 59400 is not the same as other codes. You must follow some important guidelines to ensure a fair reimbursement. Here are some essential points to consider:
- Report one unit of service for the global package
- Submit claims after delivery is complete
- Include appropriate diagnosis codes reflecting the outcome of delivery
- The date of service can be reported as either a single date (the delivery date) or a date span covering the period of care
Do Not Use for Excluded/Separately Billable Services
One of the biggest causes of 59400 denials is adding services in the claim that are not covered under the global package. Many billers don’t have a clear understanding of the bundling and unbundling rules for this code. The following services are not covered under CPT code 59400:
- Initial visit to diagnose pregnancy if the antepartum record is not initiated
- Laboratory tests (excluding routine chemical urinalysis)
- Ultrasound and imaging procedures
- Amniocentesis (any method)
- Chorionic villus sampling
- Fetal stress and non-stress tests
- External cephalic version
- E/M services for conditions unrelated to pregnancy
- Additional E/M visits for complications/high-risk monitoring (when properly documented)
- Management of surgical problems during pregnancy
Understand the Special Billing Situations
During the entire pregnancy period, some situations can complicate the billing of CPT code 59400. The following are a couple of points that you should consider before filing the claim:
Change of Insurance
When a patient changes insurance payers during pregnancy, providers should itemize services rather than using the global CPT code 59400. For example:
- Bill the first insurance payer for antepartum services provided while covered (59425, 59426, or individual E/M visits)
- Bill the second insurance payer for remaining services (antepartum, delivery, and/or postpartum as applicable)
Maternal-Fetal Medicine Specialists
When a Maternal-Fetal Medicine (MFM) specialist provides care in addition to the regular OBGYN:
- If the MFM specialist is in the same group practice as the OBGYN, they should report E/M services with modifier 25
- If the MFM specialist is in a different group practice, modifier 25 is not necessary
Final Thoughts on CPT Code 59400
CPT code 59400 is complex and requires a deep understanding of billing and CPT coding procedures. By following the guidelines mentioned in this blog, you can effectively use code 59400 to bill OBGYN services under the global package.
Successful billing with CPT code 59400 requires:
- Comprehensive documentation of all components of care
- Proper application of modifiers when circumstances warrant
- A clear understanding of services included versus excluded from the global package
If you are facing continuous claim denials or difficulty in your billing operations, consider acquiring professional OBGYN billing services from third-party billing companies.
