The American Medical Association (AMA) is dismantling the global maternity coding model.
For more than three decades, prenatal visits, delivery, and postpartum care could be reported together under a single bundled code. The positive of this reporting allowance was a streamlined billing structure. The negative was limited visibility of the individual services delivered throughout a pregnancy. That changes on January 1, 2027.
We’ve fielded many questions about this topic regarding claim editing and want to provide more clarity and context around what’s changing, how the industry is responding, the impact of these changes on health plans, and how Cotiviti is responding in support of our clients’ readiness for execution and compliance the first of next year.
In this first installment of our four-part series, we’ll take a closer look at what is changing.
The new maternity coding model is a fundamental restructuring of how maternity services are documented, billed, reimbursed, and evaluated with an encounter-based framework designed to reflect how maternity care is delivered. Instead of treating maternity care as one continuous package, the new structure divides it into four separately reported phases:
Antepartum care will be reported as individual encounters using applicable evaluation and management (E/M) services rather than bundled by prenatal visit count. This applies across office, outpatient, hospital, and telehealth settings. Pregnancy-specific ICD-10-CM codes and the TH modifier will identify antepartum or postpartum obstetrical visits. Health plans will gain greater visibility into prenatal care timing and intensity, but editing logic must distinguish appropriate maternity-related E/M reporting from duplication, incorrect code combinations, and overcoding.
Labor management will become a separate CPT section, with codes based on service day and care complexity. Services may include assessment, monitoring, examinations, and labor induction or augmentation. Complex care may involve multiple fetuses, prolonged labor, monitoring abnormalities, maternal conditions, prior cesarean delivery, or other complications. When care advances from straightforward to complex on the same day, the complex code should be reported.
Labor management may be reported once per calendar date. Hospital inpatient or observation E/M services generally may not be reported on the same date when the same physician or other qualified healthcare professional, or another clinician in the same group practice, provides both the hospital care and labor management.
Delivery care will also be reported separately, with distinct codes for vaginal, primary cesarean, and repeat cesarean deliveries. Reporting will not depend on who provided antepartum or labor-management services. Routine postpartum care on the delivery date remains included.
Certain complex procedures, including third- and fourth-degree episiotomy or laceration repairs, will also be reported separately. A new code replaces the prior add-on code for hysterectomy after cesarean delivery, requiring validation of when related procedures are separately reportable.
Existing global postpartum codes will be deleted. For facility births, postpartum care will generally use subsequent hospital care and discharge-day management codes. Routine postpartum care cannot be reported separately on the delivery date. This makes postpartum care more visible and gives health plans clearer data on post-delivery management, complications, and resource use.
Together, the four phases create more granular claims, clarify which services were performed, show when care occurred, and how complex it was. In part two of this series, we’ll examine how the industry is responding to these sweeping changes in not-so uniform ways.
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.