Forthcoming Changes to Maternity Care Billing and Coding Structure and Changes to Billing for Prenatal Care
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The purpose of this bulletin is to notify enrolled providers in fee-for-service and managed care of forthcoming changes to maternity care coding and billing requirements associated with revisions to the American Medical Association (AMA) Current Procedural Terminology (CPT®) code set for maternity care services. Effective January 1, 2027, DMAS will be transitioning to a new coding structure for maternity care services. To prepare for this change, DMAS is recommending providers begin billing Evaluation and Management (E/M) CPT codes 99202–99215 which must be used in conjunction with a -TH modifier, pregnancy-related O or Z series ICD-10 diagnostic codes for all prenatal visits, and the Category II CPT code 0500F on all initial prenatal visits — for members with an estimated due date on or after January 1st, 2027. Providers serving members who have an estimated due date before January 1, 2027, may continue to bill under current guidance through December 31, 2026. Because the AMA will delete bundled/global codes effective January 1, 2027, all claims with dates of service on or after that date must use the new coding structure — E/M codes 99202–99215 with a -TH modifier, pregnancy-related O or Z ICD-10 codes, and 0500F on initial visits — regardless of when care was initiated. Estimated Due Date (EDD) Billing Structure to Use Applicable Dates of Service Before Jan 1, 2027 Current bundled CPT codes 59400, 59425, 59426, 59510, 59610 and 59618 Through Dec 31, 2026 On or after Jan 1, 2027 New structure E&M codes with defined modifiers Mandatory for all dates of service on or after Jan 1, 2027 The following bundled/global CPT codes will be deleted and unavailable when service dates include dates on or after January 1, 2027: CPT Code CPT Description 59400 Vaginal Delivery with Antepartum and Postpartum Care 59425 Antepartum Care Only; 4-6 Visits 59426 Antepartum Care Only; 7 or More Visits 59510 Cesarean Delivery with Antepartum and Postpartum Care Vaginal Birth after Cesarean (VBAC) 59610 Delivery with Antepartum and Postpartum Care 59618 Cesarean Delivery After Attempted Vaginal Delivery with Antepartum and Postpartum Care Provider Action Items Prior to January 1, 2027, providers should begin preparing for implementation by: Support and Guidance Additional provider bulletins and implementation guidance will be issued prior to January 1, 2027, as DMAS and its contracted MCOs finalize the system changes to support the implementation of this new maternity care coding rule. DMAS will be issuing additional guidance to provide additional details on this coding change. Providers should continue following all existing Virginia Medicaid documentation and billing requirements until additional implementation guidance is issued. Additional Resources To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest. Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. 1-800-884-9730 or 1-800-772-9996 Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. Managed Care Programs Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. Cardinal Care Managed Care PACE Provider Enrollment In-State: 804-270-5105 Out of State Toll Free: 888-829-5373 Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. 1-804-786-6273 1-800-552-8627 Aetna Better Health of Virginia https://www.aetnabetterhealth.com/virginia/providers/index.html Prior Auth requests can be faxed or called to the following numbers: Phone: 1-800-279-1878 Med4/ FAMIS Fax: 1-866-669-2454 CCC Plus Fax: 1-855-661-1828 Anthem HealthKeepers Plus Prior Authorization information can be found here: https://providers.anthem.com/virginia-provider/resources/prior-authorization-requirements Call Provider Services: 1-800-901-0020 TTY: 711 Fax medical prior authorization request forms to: Inpatient fax: 1-866-920-4095 Outpatient fax: 1-800-964-3627 LTSS fax: 1-844-864-7853 Humana Healthy Horizons Provider Services Call Center https://provider.humana.com/medicaid/virginia-medicaid Prior Authorization information can be found here: https://provider.humana.com/medicaid/virginia-medicaid/prior-authorization Submit request via Availaty porta, phone or fax: Phone requests: 1-855-223-9868 or 1-844-881-4482 (TTY: 711) Fax complete form to: 1-877-486-2621. Sentara Community Plan 1-800-881-2166 https://www.sentarahealthplans.com/providers Submit authorizations via portal or phone Portal information can be found here: https://www.sentarahealthplans.com/en/providers/claims-authorizations/authorizations Phone request: 1-757-552-7474 or 1-800-229-8822 United Healthcare 1-844-284-0146 To notify UHC or request a medical prior authorization: Portal information can be found here: UHCprovider.com/priorauth or call provider services 1-844-284-0146 Acentra Health Behavioral Health and Medical Service Authorizations https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 Dental Provider DentaQuest 1-888-912-3456 Fee-for-Service (POS) Prime Therapeutics https://www.virginiamedicaidpharmacyservices.com/ 1-800-932-6648 The purpose of this bulletin is to notify enrolled providers in fee-for-service and managed care of forthcoming changes to maternity care coding and billing requirements associated with revisions to the American Medical Association (AMA) Current Procedural Terminology (CPT®) code set for maternity care services. Effective January 1, 2027, DMAS will be transitioning to a new coding structure for maternity care services. To prepare for this change, DMAS is recommending providers begin billing Evaluation and Management (E/M) CPT codes 99202–99215 which must be used in conjunction with a -TH modifier, pregnancy-related O or Z series ICD-10 diagnostic codes for all prenatal visits, and the Category II CPT code 0500F on all initial prenatal visits — for members with an estimated due date on or after January 1st, 2027. Providers serving members who have an estimated due date before January 1, 2027, may continue to bill under current guidance through December 31, 2026. Because the AMA will delete bundled/global codes effective January 1, 2027, all claims with dates of service on or after that date must use the new coding structure — E/M codes 99202–99215 with a -TH modifier, pregnancy-related O or Z ICD-10 codes, and 0500F on initial visits — regardless of when care was initiated. Estimated Due Date (EDD) Billing Structure to Use Applicable Dates of Service Before Jan 1, 2027 Current bundled CPT codes 59400, 59425, 59426, 59510, 59610 and 59618 Through Dec 31, 2026 On or after Jan 1, 2027 New structure E&M codes with defined modifiers Mandatory for all dates of service on or after Jan 1, 2027 The following bundled/global CPT codes will be deleted and unavailable when service dates include dates on or after January 1, 2027: CPT Code CPT Description 59400 Vaginal Delivery with Antepartum and Postpartum Care 59425 Antepartum Care Only; 4-6 Visits 59426 Antepartum Care Only; 7 or More Visits 59510 Cesarean Delivery with Antepartum and Postpartum Care Vaginal Birth after Cesarean (VBAC) 59610 Delivery with Antepartum and Postpartum Care 59618 Cesarean Delivery After Attempted Vaginal Delivery with Antepartum and Postpartum Care Provider Action Items Prior to January 1, 2027, providers should begin preparing for implementation by: Support and Guidance Additional provider bulletins and implementation guidance will be issued prior to January 1, 2027, as DMAS and its contracted MCOs finalize the system changes to support the implementation of this new maternity care coding rule. DMAS will be issuing additional guidance to provide additional details on this coding change. Providers should continue following all existing Virginia Medicaid documentation and billing requirements until additional implementation guidance is issued. Additional Resources To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest. Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. 1-800-884-9730 or 1-800-772-9996 Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. Managed Care Programs Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. Cardinal Care Managed Care PACE Provider Enrollment In-State: 804-270-5105 Out of State Toll Free: 888-829-5373 Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. 1-804-786-6273 1-800-552-8627 Aetna Better Health of Virginia https://www.aetnabetterhealth.com/virginia/providers/index.html Prior Auth requests can be faxed or called to the following numbers: Phone: 1-800-279-1878 Med4/ FAMIS Fax: 1-866-669-2454 CCC Plus Fax: 1-855-661-1828 Anthem HealthKeepers Plus Prior Authorization information can be found here: https://providers.anthem.com/virginia-provider/resources/prior-authorization-requirements Call Provider Services: 1-800-901-0020 TTY: 711 Fax medical prior authorization request forms to: Inpatient fax: 1-866-920-4095 Outpatient fax: 1-800-964-3627 LTSS fax: 1-844-864-7853 Humana Healthy Horizons Provider Services Call Center https://provider.humana.com/medicaid/virginia-medicaid Prior Authorization information can be found here: https://provider.humana.com/medicaid/virginia-medicaid/prior-authorization Submit request via Availaty porta, phone or fax: Phone requests: 1-855-223-9868 or 1-844-881-4482 (TTY: 711) Fax complete form to: 1-877-486-2621. Sentara Community Plan 1-800-881-2166 https://www.sentarahealthplans.com/providers Submit authorizations via portal or phone Portal information can be found here: https://www.sentarahealthplans.com/en/providers/claims-authorizations/authorizations Phone request: 1-757-552-7474 or 1-800-229-8822 United Healthcare 1-844-284-0146 To notify UHC or request a medical prior authorization: Portal information can be found here: UHCprovider.com/priorauth or call provider services 1-844-284-0146 Acentra Health Behavioral Health and Medical Service Authorizations https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 Dental Provider DentaQuest 1-888-912-3456 Fee-for-Service (POS) Prime Therapeutics https://www.virginiamedicaidpharmacyservices.com/ 1-800-932-6648
Effective January 1, 2027, DMAS will be transitioning to a new coding structure for maternity care services. To prepare for this change, DMAS is recommending providers begin billing Evaluation and Management (E/M) CPT codes 99202–99215 which must be used in conjunction with a -TH modifier, pregnancy-related O or Z series ICD-10 diagnostic codes for all prenatal visits, and the Category II CPT code 0500F on all initial prenatal visits — for members with an estimated due date on or after January 1st, 2027.
Providers serving members who have an estimated due date before January 1, 2027, may continue to bill under current guidance through December 31, 2026. Because the AMA will delete bundled/global codes effective January 1, 2027, all claims with dates of service on or after that date must use the new coding structure — E/M codes 99202–99215 with a -TH modifier, pregnancy-related O or Z ICD-10 codes, and 0500F on initial visits — regardless of when care was initiated.
Estimated Due Date (EDD) | Billing Structure to Use | Applicable Dates of Service |
Before Jan 1, 2027 | Current bundled CPT codes 59400, 59425, 59426, 59510, 59610 and 59618 | Through Dec 31, 2026 |
On or after Jan 1, 2027 | New structure E&M codes with defined modifiers | Mandatory for all dates of service on or after Jan 1, 2027 |
The following bundled/global CPT codes will be deleted and unavailable when service dates include dates on or after January 1, 2027:
CPT Code | CPT Description |
59400 | Vaginal Delivery with Antepartum and Postpartum Care |
59425 | Antepartum Care Only; 4-6 Visits |
59426 | Antepartum Care Only; 7 or More Visits |
59510 | Cesarean Delivery with Antepartum and Postpartum Care Vaginal Birth after Cesarean (VBAC) |
59610 | Delivery with Antepartum and Postpartum Care |
59618 | Cesarean Delivery After Attempted Vaginal Delivery with Antepartum and Postpartum Care |
Provider Action Items
Prior to January 1, 2027, providers should begin preparing for implementation by:
- Reviewing the new CPT maternity care codes released by the AMA
- Informing and educating staff on the forthcoming changes
- Training coding and billing staff on new billing requirements
- Assessing Electronic Health Records (EHR) workflows and charge capture processes
- Communicating with payers to understand updated reimbursement policies
- Monitoring communications from Virginia Medicaid and health plans regarding implementation requirements
Support and Guidance
Additional provider bulletins and implementation guidance will be issued prior to January 1, 2027, as DMAS and its contracted MCOs finalize the system changes to support the implementation of this new maternity care coding rule. DMAS will be issuing additional guidance to provide additional details on this coding change.
Providers should continue following all existing Virginia Medicaid documentation and billing requirements until additional implementation guidance is issued.
Additional Resources
- American College of Obstetricians and Gynecologists Statement, Payment for Obstetric Services: acog.org/practice-management/coding/coding-library/payment-for-obstetric-services
- American Medical Association CPT® 2027 Maternity Care Services code changes: https://www.ama-assn.org/practice-management/cpt/cpt-2027-maternity-care-services-code-changes
- American Medical Association recorded webinar and slides, A Health Plan Primer: Previewing the CPT 2027 Restructure for Maternity Care Services: ama-assn.org/membership/events/health-planprimer-previewing-cpt-2027-restructure-maternity-care-services
To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.
Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | |
Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | 1-800-884-9730 or 1-800-772-9996 |
Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. | |
Managed Care Programs Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. | |
Cardinal Care Managed Care | |
PACE | |
Provider Enrollment | In-State: 804-270-5105 Out of State Toll Free: 888-829-5373 Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com |
Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. | 1-804-786-6273 1-800-552-8627 |
Aetna Better Health of Virginia | https://www.aetnabetterhealth.com/virginia/providers/index.html Prior Auth requests can be faxed or called to the following numbers: Phone: 1-800-279-1878 Med4/ FAMIS Fax: 1-866-669-2454 CCC Plus Fax: 1-855-661-1828 |
Anthem HealthKeepers Plus | Prior Authorization information can be found here: https://providers.anthem.com/virginia-provider/resources/prior-authorization-requirements Call Provider Services: 1-800-901-0020 TTY: 711 Fax medical prior authorization request forms to: Inpatient fax: 1-866-920-4095 Outpatient fax: 1-800-964-3627 LTSS fax: 1-844-864-7853 |
Humana Healthy Horizons Provider Services Call Center | https://provider.humana.com/medicaid/virginia-medicaid Prior Authorization information can be found here: https://provider.humana.com/medicaid/virginia-medicaid/prior-authorization Submit request via Availaty porta, phone or fax: Phone requests: 1-855-223-9868 or 1-844-881-4482 (TTY: 711) Fax complete form to: 1-877-486-2621. |
Sentara Community Plan | 1-800-881-2166 https://www.sentarahealthplans.com/providers Submit authorizations via portal or phone Portal information can be found here: https://www.sentarahealthplans.com/en/providers/claims-authorizations/authorizations Phone request: 1-757-552-7474 or 1-800-229-8822 |
United Healthcare | 1-844-284-0146 To notify UHC or request a medical prior authorization: Portal information can be found here: UHCprovider.com/priorauth or call provider services 1-844-284-0146 |
Acentra Health Behavioral Health and Medical Service Authorizations | https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 |
Dental Provider DentaQuest | 1-888-912-3456 |
Fee-for-Service (POS) Prime Therapeutics
| https://www.virginiamedicaidpharmacyservices.com/ 1-800-932-6648 |