The global package pays once, so tracking starts at the first visit
A global obstetric code such as 59400 for vaginal delivery or 59510 for cesarean covers the routine antepartum visits, the delivery and the postpartum visit as one service, billed after delivery. Every prenatal visit must be logged against the pregnancy from the first confirmed visit, so at delivery the biller can show the antepartum visit count, who saw the patient and whether the same group delivered.
The failure mode is quiet. Antepartum visits get posted as ordinary E/M visits, then the global code is billed at delivery, and the payer sees the same care twice. Or the visits are held correctly, the patient delivers elsewhere, and nobody bills the antepartum care because the delivery trigger never came. We keep an open obstetric ledger per patient in your practice management system and reconcile it monthly.
Split care: when the package breaks apart
Patients transfer in, move away in the third trimester, change insurance mid-pregnancy, or are delivered by a hospitalist group that is not yours. Then the global code no longer applies and the care is billed in pieces: four to six antepartum visits with 59425, seven or more with 59426, one to three as individual E/M encounters. Delivery alone is 59409 or 59514, delivery with postpartum care is 59410 or 59515, and postpartum care alone is 59430.
A payer change costs the most. The first insurer owes the antepartum visits under its coverage; the second owes the delivery and whatever followed. Billing the whole global to the second payer, which most systems do by default, gets the claim denied or recouped. We date-stamp the coverage change, split the ledger there and bill each payer its own portion.
Ultrasound, non-stress tests and the services the package does not include
The global package covers routine care, not everything in a pregnancy. Obstetric ultrasounds (76801 in the first trimester, 76805 after it, 76811 for the detailed fetal anatomic survey, 76815 for a limited study and 76816 for follow-up), non-stress tests (59025), biophysical profiles, and management of complications such as gestational diabetes or hypertension are separately billable when the documentation supports it.
Two things go wrong. A complication visit is documented as a routine prenatal check and absorbed into the global instead of billed as an E/M visit with the complication diagnosis. Or 76811 is billed without the indication and the additional anatomic elements that distinguish it from 76805, and the payer downgrades or denies it. We review ultrasound reports against the code before submission and flag problem-pregnancy visits to the provider when the note reads as routine.
Devices, office procedures and the authorization trail
On the gynecologic side, the recurring work is contraceptive devices. An IUD or implant is two claims in one: the insertion (58300 for an IUD, 11981 for an implant) and the device under its own J code. The device is where the money and the denials are: a plan that covers the insertion may route the device to the pharmacy benefit, require an NDC, or cover only certain brands.
Colposcopy with biopsy (57454), endometrial biopsy (58100), LEEP (57460 and 57461), hysteroscopy and the surgical procedures mostly carry a 90-day global and often need prior authorization. We verify the authorization against the specific code scheduled, not the procedure name, because a laparoscopic hysterectomy authorized as 58571 and performed as 58573 will deny.
Preventive billing: the well-woman visit that becomes a problem visit
An annual gynecologic exam is billed as a preventive visit (99385 through 99397 by age and patient status) or, for Medicare, as G0101 for the pelvic and breast exam plus Q0091 for obtaining the Pap specimen. Preventive services are often covered without cost sharing, which is why payers scrutinize them. When the same visit also addresses abnormal bleeding or a breast lump, a separate problem-oriented E/M with modifier 25 is appropriate, and the patient may owe a copay on it.
Practices that never bill the problem visit undercode; practices that bill it every time get audited. The note must show a separately identifiable problem and the work done on it. Medicare adds frequency rules for G0101 and Q0091 that depend on risk status, so we check the screening history before submission rather than letting an early screening deny onto the patient.
Taking over OB/GYN billing with pregnancies in progress
The hardest part of switching billers in obstetrics is pregnancies already underway. Some patients are at six weeks, some at thirty-six, and each has antepartum visits held somewhere that must reach the global claim at delivery. Before the switch, we build the open obstetric ledger from your schedule and prior biller’s notes, confirm each patient’s coverage and expected delivery date, and identify those whose insurance has changed since the first visit.
The two-to-four-week parallel run does double duty: we watch how the outgoing biller holds antepartum visits and correct the ledger before we own it. The first step is a free A/R review, which includes last year’s deliveries that never produced a global claim or produced one that denied. Those are usually the largest recoverable balances you have. Terms are month-to-month after the initial period, under a signed BAA, with a named account manager.
