In part one of this four-part series, we reviewed the fundamental changes being introduced the American Medical Association’s (AMA) maternity care coding effective January 1, 2027. In part two, we examined the misalignment and current uncertainty evidenced by opposing responses from industry leadership.
To recap, AMA maternity care coding is shifting away from service bundling. CMS is considering 15 Medicare-specific HCPCS G-codes that would preserve the traditional global maternity model for Medicare payment in lieu of adopting the new maternity CPT framework, while ACOG supports the new CPT structure and has urged CMS to reject the proposed G-codes. The final Medicare approach remains pending, and state Medicaid programs may adopt different implementation requirements.
In this installment, our focus will be on the impact these maternity care coding changes have on health plans specifically.
A real opportunity for improvement, but not without effort
The move to encounter-based reporting offers health plans an opportunity to gain a clearer, more detailed view of maternity care. Labor complexity and escalation can become visible in claims data. Antepartum and postpartum encounters can be evaluated individually. Delivery-related procedures can be distinguished with greater precision. Over time, the resulting data may support quality measurement, risk adjustment, and analysis of maternal morbidity and mortality.
Realizing those benefits, however, requires substantial preparation. Claims-processing rules designed for a global maternity package cannot simply be carried forward. Health plans must account for newly reportable services, deleted codes, revised code relationships, calendar-day requirements, complexity distinctions, bundling rules, and the increased use of E/M codes for prenatal and postpartum care.
The impact may extend across payment and reimbursement policies, clinical and coding edits, provider contracts and billing expectations, Medicare, Medicaid, and commercial configurations, client-specific customizations, provider education, and communication. Impact may also be seen in reporting, analytics, quality programs, claim testing, and implementation validation.
The transition period creates additional consideration. AMA and ACOG guidance encourage providers to begin reporting prenatal care through E/M services during 2026 when the pregnancy is expected to continue into 2027.
Final thoughts
Health plans must prepare for claims with dates of service beginning January 1, 2027, and for maternity episodes that cross the implementation date. Editing logic must support the transition without treating appropriate prenatal E/M reporting as inherently inconsistent with the historical global model.
The operational question is no longer simply whether an organization has entered the new codes, but whether its policies, editing logic, configurations, and testing approach reflect how those codes interact throughout the full maternity episode. In part four of this series, we’ll share what Cotiviti is doing to prepare and support our clients for January 2027 execution.
If you have questions around maternity coding changes or would like to learn how Cotiviti is helping our clients with January 1 maternity code compliance readiness, request a conversation, speak to your primary representative, or share you questions at answers@cotiviti.com.
