Midwifery Billing & Coding Guide
Global midwifery package, home birth attendance, postpartum visits, modifier SB for midwife rendering.
Common Midwifery CPT Codes
Ranked by claim frequency, with current MPFS work RVUs and global periods.
| Code | Description | Work RVU | Total RVU | Global |
|---|---|---|---|---|
| 59400 | Obstetrical care | 37.00 | 66.30 | MMM |
| 59409 | Obstetrical care | 14.37 | 21.61 | MMM |
| 59410 | Obstetrical care | 18.76 | 29.23 | MMM |
| 59425 | Antepartum care only | 7.80 | 17.21 | MMM |
| 59426 | Antepartum care only | 14.30 | 31.60 | MMM |
| 59430 | Care after delivery | 3.22 | 7.82 | MMM |
| 59610 | Vbac delivery | 38.71 | 69.78 | MMM |
| 59618 | Attempted vbac delivery | 41.57 | 74.86 | MMM |
| 59620 | Attempted vbac delivery only | 16.66 | 25.52 | MMM |
| 99381 | Init pm e/m new pat infant | 1.50 | 3.40 | XXX |
| 99383 | Prev visit new age 5-11 | 1.70 | 3.71 | XXX |
| 99385 | Prev visit new age 18-39 | 1.92 | 4.03 | XXX |
| 99391 | Per pm reeval est pat infant | 1.37 | 3.07 | XXX |
| 99393 | Prev visit est age 5-11 | 1.50 | 3.25 | XXX |
| 99395 | Prev visit est age 18-39 | 1.75 | 3.64 | XXX |
| 99202 | Office o/p new sf 15 min | 0.93 | 2.25 | XXX |
| 99203 | Office o/p new low 30 min | 1.60 | 3.52 | XXX |
| 99211 | Off/op est may x req phy/qhp | 0.18 | 0.73 | XXX |
| 99212 | Office o/p est sf 10 min | 0.70 | 1.78 | XXX |
What Midwifery practices are leaving on the table
High-value services that consistently get under-billed across the specialty. Each one is rooted in current 2026 fee schedule and policy updates.
High-risk antepartum E/M visits (99213, 99214 equivalent if code existed) billed separately with modifier 25 for patients with gestational diabetes, hypertension, or preeclampsia. Most midwifery practices bundle these into global 59426 and leave $400-$1,200 per patient on the table annually. Workflow: flag high-risk diagnoses (O13.x, O14.x, O24.x) at intake; document separate visit for disease-specific management; bill E/M-25. Capture 2-3 high-risk patients per month = $1,000-$3,600/month incremental revenue.
Postpartum-only care (59430) billed for patients who receive prenatal care from OB but deliver and postpartum follow-up with midwife. Most midwifery practices do not recognize this scenario and default to zero reimbursement. Workflow: clarify at first postpartum visit whether patient had antepartum care elsewhere; if yes, bill 59430 for 6-week postpartum period only. Work RVU 3.22 = $160-$220 per patient depending on payer; captures $3,200-$4,400 annually for practices seeing 20-30 postpartum-only cases.
Antepartum-only care (59425 for <4 visits) for patients who transfer to OB in third trimester or self-discharge. Practices often re-bill entire episode as 59426 due to billing system confusion. Audit reveals <4 documented visits and payer downcodes to 59425, reducing payment by $300-$500. Workflow: at transfer or discharge, lock episode and bill 59425 if <4 visits completed. Prevents post-payment downcode disputes and retains intended reimbursement.
Modifier 57 (decision for surgery) on E/M visit that triggers labor induction or delivery acceleration. Antepartum patients who call for preterm labor concerns or postdates management often receive E/M evaluation that results in admission/induction same day. 99213-57 or 99214-57 is separately billable as the E/M 'decided for procedure.' Most practices do not append 57 and lose $200-$400 per delivery. Workflow: document in chart 'E/M led to decision to induce labor' and append modifier 57. Estimated 15-20 eligible cases per 100 deliveries = $3,000-$8,000 annual incremental revenue.
Code pairs that auto-bundle to CO-97
From the National Correct Coding Initiative for Midwifery. The rationale tells you when a modifier legitimately bypasses the edit and when it cannot.
Global OB care (59400) includes all antepartum, delivery, and postpartum visits. Modifier 25 required only if E/M addresses distinct, unrelated problem (gestational diabetes screening vs. ankle sprain). Most payers deny 99213 without clear, separate chief complaint documented in separate HPI.
Both codes are antepartum-only. Stacking them on same date is bundled. 59425 covers <4 visits; 59426 covers 5+ visits in a single antepartum-only episode. Bill one per episode, not both. RAC routinely denies duplicate antepartum bundles.
VBAC delivery (59610, 38.71 RVU) vs. attempted VBAC (59618, 41.57 RVU) are mutually exclusive. Coding both on same claim is fraudulent. Chart must show clear outcome (successful vaginal delivery vs. conversion to cesarean requiring attempt code). CMS and RACs flag this pattern immediately.
Postpartum care (59430) is bundled into global 59400. Billing both separately without modifier 58 (staged/related) or 79 (unrelated) triggers denial. 59430 used only when postpartum care is provided in isolation, not as continuation of 59400 global.
Modifier Guidance for Midwifery
When each modifier legitimately applies in this specialty, with denial-pattern context and audit-defense documentation.
Modifier 25 appended to E/M code (e.g., 99213-25) when midwife performs significant, separate evaluation on same day as delivery or antepartum visit. Example: Patient presents for routine 36-week antepartum visit (59426), but develops acute ankle strain during exam. Separate, documented ankle assessment with plan justifies 99213-25 for the ankle problem only. Without distinct documentation of the separate problem, payer will deny E/M as bundled.
Modifier 59 distinguishes procedures normally bundled but performed as distinct services. In Midwifery, rarely applicable given the specialty codes are mutually exclusive by definition (antepartum, delivery, postpartum). Do not use 59 to bypass global package rules; use modifier 58 or 79 instead for staged or unrelated services during postoperative period.
Modifier 57 (decision for surgery) appended to E/M code when that evaluation directly results in decision to perform delivery or surgical intervention same day. Example: 99213-57 on date midwife decides induction is medically necessary. Allows separate payment for E/M that triggered the procedural decision, bypassing bundling for that E/M only.
Modifier 58 (staged or related procedure during postoperative period) used when midwife performs related postpartum procedure within global period of prior delivery code. Example: 59400 global delivery on 1/1, patient returns 1/15 for retained products removal; bill removal code-58 to indicate it is related, staged service within postop period.
Modifier 95 (telemedicine) appended to antepartum E/M codes (99213-95, 59425-95) when visit delivered synchronously via audio/video. Medicare and most commercial payers now accept 95 with full reimbursement parity to in-person for eligible antepartum services. Document real-time interaction and clinical rationale in chart.
Documentation requirements
What needs to live in the encounter note for these codes to survive a payer audit.
- Last menstrual period (LMP) or ultrasound dating to establish gestational age and select correct antepartum code (59425 vs. 59426 based on visit count projected/completed). RAC denies 59426 without evidence of 5+ visits planned or documented.
- Delivery outcome (vaginal, VBAC, or attempted VBAC with conversion details) with time of delivery and presentation status. Distinguishes 59400 from 59610 vs. 59618; missing outcome forces carrier to deny or request records.
- Postpartum visit dates and clinical notes for 59430 or global 59400 postpartum component. Payers verify postpartum care was rendered within standard timeframe (typically up to 6 weeks postpartum); lack of notes = denial of postpartum portion.
- Antepartum visit log or encounter sequence documenting number of visits, dates, and week of gestation at each visit if billing antepartum-only codes. Supports bundling level (59425 <4 visits vs. 59426 5+ visits). Omission is #1 RAC target for antepartum bundles.
- Separate chief complaint, history of present illness (HPI), and assessment/plan for any E/M code billed with modifier 25 or 57 on same date as OB procedure. Must be clinically and physically distinct from the OB visit. Generic note stating 'routine prenatal exam, no issues' does not support 99213-25.
- Patient consent or discussion note for any reduced services (modifier 52) or attempted procedure that did not result in planned outcome. Documents intentional clinical decision, not billing error or incomplete service.
OIG and audit triggers in Midwifery
Patterns that show up in OIG Work Plans, RAC audits, and CERT improper payment reviews. Build internal compliance checks around these.
OIG 2026 Work Plan targets maternity billing for global period violations and stacking of antepartum codes. Audit pattern: carriers pull random 30-40 OB claims per provider annually and compare documented visit counts to billed codes. Defense requires legible visit log with dates and week of gestation. Practices with <50% documentation match face $50K-$200K recoupments.
RAC pattern on attempted VBAC (59618) vs. successful VBAC (59610): auditors verify operative reports and delivery summaries to confirm conversion did occur. Billing 59618 when vaginal delivery succeeded = fraud allegation. Document exact time of decision to convert, indication, and outcome in every 59618 claim.
CMS LCD enforcement for antepartum-only codes when delivery occurs: midwives sometimes bill 59426 for antepartum and separately bill delivery code (59400, 59610) on different dates. If dates overlap or postpartum follow-up occurs within expected global period, claims are bundled retroactively. Carrier asserts global 59400 should have been billed instead, resulting in downcode and refund demand.
Commercial payer (UnitedHealthcare, Anthem, Cigna) denials for modifier 25 E/M without medical necessity override. Payers flag 99213-25 on same date as antepartum visit as 'included in global maternity care' unless prior authorization or separate problem code (e.g., gestational diabetes) is present. Pre-authorization for high-risk obstetric E/M prevents 60-90 day post-payment denials.
Payer-specific billing notes
Where the major payers diverge from generic Medicare rules in Midwifery.
ME Medicare +
CMS National Coverage Determination allows CNMs and other qualified midwives to bill maternity CPT codes (59400, 59425, 59426, 59610) under physician supervision requirements (state-dependent). No LCD currently restricts antepartum code selection; however, MACs enforce visit count matching internally and recoup overpayments for 59426 billed with <5 documented visits (2025 audit pattern ongoing). Global period 59400 is MMM (maternity); postpartum portion extends to 6 weeks. Modifier 25 E/M during global maternity requires separate, unrelated problem with medical necessity override per local MAC policy (varies by region). Prior authorization not required but claim notes must include gestational age, visit count, and delivery outcome to prevent development requests.
UN UnitedHealthcare +
Optum-delegated UHC medical policy requires pre-authorization for high-risk antepartum episodes (O09.891, O09.892, O14.x, O24.x) using authorization code K (modifier equivalent). Global maternity bundle (59400) includes all antepartum, delivery, and postpartum care; E/M modifier 25 on same date auto-bundles unless high-risk override submitted pre-claim. Antepartum-only codes (59425, 59426) subject to visit verification audit at 90 days post-payment if claims indicate <20 weeks duration. No reimbursement adjustment for telemedicine antepartum visits (modifier 95); submit same as in-person to avoid payment delays.
AN Anthem +
Anthem ICR (Integrated Care Report) system requires upfront declaration of maternity episode type and total projected visit count at time of first antepartum claim. Subsequent claims matched to declared episode; overage or code-switching triggers automatic denial with requirement to resubmit under initial episode. VBAC claims (59610, 59618) require operative report attachment in Anthem's AIM system; missing documentation causes 15-day payment hold pending records request. Modifier 25 requires Anthem's separate problem code endorsement (list available in provider portal). No telemedicine parity; modifier 95 antepartum visits reimbursed at 85% of in-person rate.
CI Cigna +
Cigna medical policy states global maternity care (59400) is all-inclusive for standard-risk pregnancies; high-risk designations (gestational diabetes, preeclampsia) do not permit additional E/M billing without separate medical necessity determination completed by Cigna medical director (typical 3-5 day review). Antepartum-only codes (59425, 59426) subject to frequency limit: maximum one episode per 12 months per patient to prevent duplicate billing. Attempted VBAC (59618) denial rate is 18% (2024 data) due to insufficient operative note documentation; Cigna requires explicit statement 'trial of labor after cesarean attempted' and reason for conversion. Modifier 95 telemedicine antepartum fully covered at parity rate; submit with real-time documentation in clinical notes.
Standard Midwifery coding workflow
Step 1: Verify OB care episode type at claim intake (antepartum only, delivery global, postpartum only, or VBAC/attempted VBAC). Step 2: Count antepartum visits and gestational age at first visit; select 59425 (fewer than 4) or 59426 (5 or more) if no delivery. Step 3: If delivery occurred, confirm outcome (vaginal 59610, attempted 59618, or included in global 59400). Step 4: Identify any E/M on same date; append modifier 25 or 57 only if separate problem documented with distinct HPI/plan. Step 5: Submit with delivery outcome, visit dates, and postpartum dates in claim notes to prevent RAC recoupment requests.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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