Maternity Care Shifts from Bundled to Fee-for-Service Billing in January, Raising Cost Concerns

New billing codes for maternity care take effect in January. Doctors who manage maternity care will start charging a la carte for visits and services related to pregnancy, childbirth, and postpartum care under the new codes. The change reverses recent years when doctors often received a single bundled payment for maternity care.

The American College of Obstetricians and Gynecologists strongly backs the change and has pushed for it for years. Lisa Hofler, chair of the Department of Obstetrics and Gynecology at the University of New Mexico and a member of the ACOG committee that developed the new codes with the American Medical Association, said the current bundled system sets prenatal visits at 13 regardless of patient needs.

The new fee-for-service codes will accommodate more or fewer visits, in person or remotely, based on individual requirements.

Hofler also noted that under the current system, labor and delivery are reported with one code regardless of duration or complications. The new codes will allow hospitalists focused on labor and delivery, midwives, and maternal-fetal medicine specialists to account for and receive payment for the range of services they provide.

Laurie Zephyrin, an OB-GYN and senior vice president for the Achieving Equitable Outcomes initiative at The Commonwealth Fund, said the cost piece is really critical because there will be more line items.

She asked whether those costs will be passed along to patients, particularly those in commercial plans or high-deductible plans. Whether families will pay more out-of-pocket really comes down to how payers choose to implement these codes, Zephyrin said.

Chris Bond, a spokesperson for AHIP, said rushed implementation of far-reaching AMA code restructuring will change how maternity services are managed and reimbursed.

Providers and health plans use standardized codes for diagnoses, procedures, services, and supplies under federal law. Doctors and other health professionals bill for their services using Current Procedural Terminology codes developed and maintained by the American Medical Association.

The federal Centers for Medicare & Medicaid Services reviews new and revised codes and reimburses clinicians based on a fee schedule updated every year.

The CMS review of the new maternity codes is going on now, and the proposed fee schedule for next year will be published in July. Barbara Levy, vice chair of the AMA's CPT Editorial Panel, said they do not know whether CMS will go along with the proposed coding changes. CMS were at the table as observers and had opportunities to give inputs throughout the entire process, Levy said.

The AMA is educating providers and payers about the new coding structure. Under the ACA, most health plans have to provide maternity care that is considered preventive at no cost to members. The list of preventive maternity services set by the federal Health Resources and Services Administration includes prenatal and postpartum visits and screening for diabetes, anxiety, and HIV.

6 million babies are born every year in the United States. It costs families with employer coverage $2,743 on average according to an analysis of data from 2021 to 2023 by researchers with the Peterson-KFF Health System Tracker.

U.S. Are covered by the federal-state Medicaid program. , now provide a full year of Medicaid coverage after childbirth, up from 60 days. Under the new codes, physicians will be paid to provide extended postpartum care rather than the two visits that were recommended under bundled coding.

ACOG recommends a detailed first-trimester ultrasound for pregnant patients 35 years or older or with known risk factors, according to spokesperson Jamila Vernon. Subsequent ultrasounds are also based on findings and risk factors, and there is no set number of ultrasounds for all patients, Vernon said. The proportion of births by C-section has not changed under bundled payment.