Separate E/M Services During Pregnancy: What Falls Outside Global Maternity Care

Global maternity care and its limits

Global obstetric codes bundle routine antepartum care, delivery, and postpartum care into a single payment. Routine antepartum care, as described by CPT and ACOG guidance, typically includes monthly visits up to 28 weeks, biweekly visits to 36 weeks, and weekly visits until delivery, along with routine urinalysis, weight, blood pressure, and fetal heart tone checks. Because the package is broad, many practices assume every visit during pregnancy is included. That is not true. Visits for conditions unrelated to pregnancy, and visits for complications that require additional work beyond routine care, can often be billed separately with appropriate documentation.

Problems unrelated to pregnancy

When a pregnant patient is seen for a condition unrelated to the pregnancy, such as a urinary tract infection, an upper respiratory infection, a skin rash, or management of a chronic condition like asthma, an E/M may be reported separately. The note should clearly separate that problem from routine prenatal care, and the diagnosis should reflect it. Some payers expect modifier 25 on the E/M when it occurs on the same day as a routine prenatal visit, while others, especially with global billing, expect no modifier but a clearly distinct diagnosis. Check payer policy.

Pregnancy complications that add work

ACOG guidance and payer policies recognize that medical complications of pregnancy, such as gestational diabetes, preeclampsia, hyperemesis, preterm labor, or significant bleeding, may require additional visits beyond the routine schedule. Those additional visits, when they exceed the normal number of antepartum visits and are documented as management of the complication, may be billed separately as E/M services. Routine visits that include brief attention to a complication, however, remain part of the global package. Documentation should show the additional work, the complication being managed, and the clinical decisions made.

High-risk pregnancies

For high-risk pregnancies, practices may see patients far more often than the routine schedule. Payers vary in how they want this reported. Some accept additional E/M visits with complication diagnoses, while others pay enhanced fees through specific codes or authorization. Maternal-fetal medicine consultations are typically billed by the consultant separately. Fetal monitoring, such as nonstress tests, and ultrasounds are reported separately from the global package when performed, because they are not part of routine care under CPT definitions.

Choosing the E/M level

Separate pregnancy-related E/M visits follow the same medical decision making or time rules as any office visit. Visits for complications such as preeclampsia evaluation may involve multiple data points and moderate or high risk decisions, while a simple unrelated problem may support a lower level. Avoid using time that was spent on routine prenatal elements to select a separate E/M level when the routine visit is part of the global package.

Diagnosis coding during pregnancy

ICD-10-CM chapter 15 codes for pregnancy, childbirth, and the puerperium take sequencing priority when a condition complicates pregnancy or is affected by it. When a provider documents that a condition is incidental to the pregnancy and unrelated to it, code Z33.1, pregnant state, incidental, may be used along with the condition. Getting this right affects whether the payer recognizes the visit as outside the global package, so coders should read the provider's statement carefully.

Building a review process

Many OB practices lose revenue by never billing separate visits, while others risk audits by billing every visit with a complication diagnosis. A monthly review of a sample of prenatal charts against payer rules strikes a balance. Look for complication visits that exceeded the routine schedule but were not billed, and for separately billed visits that were actually routine. Educate providers to clearly label problem-oriented portions of a note so coders can identify billable services.

Communicating with patients about separate charges

Patients often believe that everything during pregnancy is covered by one maternity payment, so a separate bill for a problem visit can come as a surprise. A brief explanation at the start of prenatal care helps: routine prenatal visits are included in the maternity package, while visits for unrelated illnesses or for extra management of complications may be billed separately and may carry copays or coinsurance. Many practices include this in their financial policy and review it during the first prenatal appointment along with the estimate of the patient's share of global maternity charges. Front desk staff can also flag visits scheduled as sick visits so the patient knows to expect a separate claim. Clear communication reduces billing disputes, supports collections, and helps patients understand that the practice is billing accurately, not adding charges arbitrarily. It also keeps patient-facing staff aligned with the coding team's decisions about what falls inside the package.

Frequently asked questions

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