OB/GYN Medical Billing: Complete Guide for Obstetrics & Gynecology Practices 2026

OB/GYN Medical Billing: Complete Guide for Obstetrics & Gynecology Practices

OB/GYN medical billing encompasses a unique blend of surgical procedures, preventive care, maternity packages, and chronic condition management. From global maternity care and delivery coding to gynecological surgeries and well-woman visits, understanding the specific billing requirements, bundled payment structures, and modifier applications is essential for maximizing reimbursement while maintaining compliance.

Global Maternity Care and Delivery Coding

The global maternity package includes antepartum care, delivery, and postpartum care bundled into a single code. Understanding what's included versus separately billable prevents denials and ensures proper reimbursement. Routine prenatal visits, one postpartum visit, and vaginal or cesarean delivery are all included in the global package. Complications, ultrasounds beyond routine screening, and non-routine procedures are separately billable.

When patients transfer care or deliver at a different facility, partial billing codes must be used based on where care was provided. Antepartum-only codes, delivery-only codes, and postpartum-only codes allow proper billing when the same provider doesn't deliver all components. Documentation must clearly indicate the reason for split billing and which provider performed each service component.

Gynecological Surgery and Procedure Coding

Gynecological procedures range from minor office-based procedures to major abdominal surgeries. Hysterectomy coding requires accurate identification of approach (vaginal, abdominal, laparoscopic, robotic), extent (total, subtotal), and concurrent procedures. Each variation has distinct CPT codes affecting reimbursement significantly. Documentation must specify surgical approach, organs removed, and complications encountered.

Endometrial ablation, hysteroscopy, colposcopy, and LEEP procedures each have specific coding requirements. Understanding when diagnostic procedures are bundled versus separately billable prevents compliance issues. Surgical procedures include diagnostic visualization, so billing both diagnostic and surgical codes for the same session constitutes unbundling unless distinct sessions or circumstances apply.

Preventive Care and Screening Services

Well-woman visits include age-appropriate screenings, counseling, and preventive services. Understanding the difference between preventive visits and problem-focused visits is critical for proper coding. When problems are addressed during preventive visits, modifier 25 allows billing an additional E/M service if significant separately identifiable evaluation occurs beyond the preventive service.

Pap smears, HPV testing, and cervical cancer screening follow specific coding guidelines based on patient age, screening intervals, and risk factors. Medicare and commercial payers have different coverage policies for screening frequencies. Documentation must support medical necessity for any screenings performed outside standard guidelines to prevent denials.

High-Risk Pregnancy and Complication Management

High-risk pregnancies require additional monitoring and interventions beyond routine prenatal care. Conditions like gestational diabetes, preeclampsia, preterm labor, and multiple gestations necessitate additional visits, testing, and procedures that are separately billable from the global package. Proper documentation of medical necessity and appropriate ICD-10 coding is essential for reimbursement.

Fetal monitoring, non-stress tests, biophysical profiles, and ultrasounds for high-risk conditions are separately billable when medically necessary. Each service requires documentation supporting why it was performed beyond routine care. Payers often require prior authorization for frequent monitoring or specialized testing in high-risk pregnancies.

Office Procedures and Modifier Usage

Common office procedures like IUD insertion/removal, Nexplanon placement, endometrial biopsies, and colposcopy with biopsy require accurate coding and appropriate modifier usage. Modifier 25 is frequently used when significant E/M services occur on the same day as minor procedures. Documentation must clearly demonstrate the separately identifiable nature of the evaluation.

Bilateral procedures require modifier 50 or separate line items with LT/RT modifiers depending on payer preference. Multiple procedures performed during the same session follow standard multiple procedure payment rules with the highest-valued procedure at 100% and additional procedures at reduced rates. Understanding NCCI edits prevents bundling errors and claim denials.

Infertility Treatment and ART Billing

Assisted reproductive technology services including IUI, IVF, egg retrieval, and embryo transfer have limited insurance coverage with many services being patient-pay. Understanding which diagnostic services are covered versus treatment services helps set proper patient expectations. Some states mandate infertility coverage while others provide minimal or no coverage.

When insurance does cover infertility services, prior authorization is typically required. Documentation must establish medical necessity, appropriate workup completion, and failed less-intensive treatments when applicable. Practices should have clear financial policies for ART services given variable insurance coverage and high out-of-pocket costs.

Successful OB/GYN billing requires specialized knowledge of global maternity care, gynecological surgery coding, preventive service guidelines, and payer-specific requirements. Practices that partner with experienced billing services achieve improved collections, reduced denials, and optimal revenue capture across all service lines.