New Billing Codes May Increase Pregnancy Care Costs

Introduction: A Shift in Maternity Billing

As we approach the new year, a significant change in how maternity care is billed is set to take effect. The transition from bundled to fee-for-service billing will impact not only how providers are compensated but also how patients experience healthcare costs related to pregnancy, childbirth, and postpartum care.

The Current State of Maternity Billing

For years, the standard practice in maternal healthcare has been a bundled payment system. Under this model, physicians receive a single fee that covers all aspects of pregnancy-related care—from prenatal visits to delivery and postpartum follow-up. This structure was designed to simplify billing and reduce administrative burden.

"The global bundle doesn't cover everything," said healthcare expert Laurie Zephyrin. "There will be more line items, and whether those costs are passed along to patients is an open question."

However, this approach has its limitations. The number of prenatal visits is often arbitrary, typically capped at 13—despite the fact that modern expectant mothers may require more or fewer visits based on individual health needs.

Why the Change?

The American College of Obstetricians and Gynecologists (ACOG) has long advocated for this change, citing a need to reflect the complexity and variability in maternal care. As expectant mothers age and face more complex medical conditions, the old system fails to account for personalized treatment plans.

Dr. Lisa Hofler, chair of the Department of Obstetrics and Gynecology at the University of New Mexico, emphasized that current codes do not support diverse patient needs or modern healthcare delivery models:

"Under the current system, if someone comes in for a birth, no matter how long or complicated their labor, the global reporting is the same because we only have one code," Hofler explained.

The new codes will enable providers to accurately bill for each service delivered, including remote consultations, multiple practitioners involved in care, and specialized services such as those provided by maternal-fetal medicine specialists or midwives.

Implications for Patients

This shift may have financial implications for patients, particularly those enrolled in high-deductible health plans. Experts are concerned that the move back to a fee-for-service system could increase out-of-pocket expenses due to greater specificity in billing and more frequent testing.

For example, under the new framework:

• Patients may receive itemized bills for each prenatal visit
• Ultrasounds and lab work will be charged separately
• Labor and delivery fees may include additional components previously bundled into a single charge

Caitlin Donovan, senior director at the Patient Advocate Foundation, expressed skepticism about this direction:

"I always worry about anything that is 'piecemealing' our healthcare system even more," she said.

Donovan shared a personal experience where her obstetrician recommended weekly ultrasounds during her third pregnancy, despite no clinical indication for such frequent monitoring:

"There was nothing that indicated I needed those scans. It was just a money grab," she recalled.

Industry Perspectives

The insurance industry has voiced concerns about the implementation timeline, which requires significant operational changes. Industry spokesperson Chris Bond noted:

"Rushed implementation of far-reaching AMA code restructuring will fundamentally change how maternity services are managed and reimbursed," he stated.

Insurance representatives also worry that providers may be incentivized to offer more tests or procedures under a fee-for-service model, increasing overall healthcare spending.

The Role of Federal Regulations

Under federal law, standardized codes for diagnoses and services are required. These codes are developed by the American Medical Association (AMA) and reviewed by the Centers for Medicare & Medicaid Services (CMS), which sets reimbursement schedules annually. Although CMS has been involved in reviewing the proposed changes, their final decision remains pending.

Barbara Levy, vice chair of the AMA's CPT Editorial Panel, emphasized:

"We don't know whether CMS will go along with the proposed coding changes," Levy said. "They were at the table as observers and had opportunities to give inputs throughout the entire process."

Preventive Care Protections

Certain preventive services, including prenatal visits, postpartum care, and screening for diabetes, anxiety, and HIV, are mandated under the Affordable Care Act (ACA) to be provided at no cost to members. However, many other aspects of maternity care—such as ultrasounds, specialist visits, and labor and delivery fees—are not included in this coverage and remain subject to patient payment.

It's important to note that while Medicaid covers most maternity care for low-income individuals, the shift in billing codes will not affect their financial burden. Nevertheless, these changes could improve access to comprehensive postpartum care, which is currently limited under the bundled system.

Maternal Health Outcomes and Postpartum Care

One of the primary goals of implementing the new billing codes is to enhance maternal health outcomes. With a more detailed breakdown of services provided during pregnancy and after birth, researchers can better evaluate which interventions improve health outcomes, especially regarding maternal mortality rates.

Maternal-fetal medicine experts are particularly interested in expanding postpartum coverage. Currently, only two visits are recommended under the bundled model; however, with the new system, physicians will be compensated for extended postpartum care.

Kay Johnson, president of Johnson Policy Consulting, highlighted:

"With the new codes, you have that opportunity for ongoing care, and you have a way to finance it," she said.

Employer Concerns

Representatives from large employers who self-fund employee health benefits are also watching closely. Jeff Levin-Scherz, population health leader at WTW's health management practice, noted that even though patients may not directly pay for visits, increased visit intensity could drive up premiums.

"It's not likely that this new set of visit codes will be exempt from that," he said. "If their plan is paying more next year, their insurance premiums will go up more."

Magda Rusinowski, vice president at the Business Group on Health, echoed similar concerns:

"Fee-for-service in every discipline incentivizes more tests and higher-level providers because that's what generates higher billing," she said.

The Bigger Picture

With approximately 3.6 million babies born annually in the United States, childbirth remains one of the most common medical events people experience. Despite efforts to reduce costs through bundled payments, cesarean section rates have not significantly decreased under this model.

This new system could be a step toward addressing long-standing challenges in maternal healthcare delivery:

• Improved tracking and measurement of services provided
• Better alignment between care delivered and payment structures
• Potential for enhanced postpartum support, particularly for mothers with complex needs

As the healthcare landscape evolves, it's essential to balance innovation in billing practices with considerations for patient affordability and access. The coming months will be critical in determining whether these changes result in improved outcomes or unintended financial consequences.

Conclusion: Navigating the Future of Maternity Care

The upcoming shift in maternity billing codes represents a pivotal moment for maternal healthcare. While ACOG and physicians advocate for greater accuracy in reimbursement, the potential increase in patient costs warrants careful scrutiny. Employers, insurers, and policymakers must work collaboratively to ensure that these changes enhance rather than hinder equitable access to quality maternal care.

As we continue to monitor the implementation of these new codes, one thing remains clear: the future of maternity care depends not only on medical innovation but also on thoughtful policy decisions that prioritize both provider compensation and patient affordability.