#190 Every Prenatal Visit Is Now a Billable Event

Starting January 1, 2027 every antepartum visit becomes its own billable E/M charge. The global OB code goes away. The seventeen deleted codes include 59400, 59510, 59425, and 59426. And the way most prenatal notes are written today supports a 99212 at best, even when the visit was genuinely a 99214. Dr. Heather Signorelli and Maria Reynoso, Director of RCM at NatRevMD, walk through what changes, what the notes have to say, and the three actions every OB practice should take this week. 

What changes January 1, 2027: 

Antepartum-only codes (59425, 59426) and global OB codes (59400, 59510) are deleted. Every prenatal visit is now a standard E/M visit with modifier TH. New patient 99202–99205. Established patient 99211–99215. 

What the notes actually look like today: 

Notes have been written for speed because the global model did not reward note detail. A typical 16-week prenatal note (BP, fundal height, FHTs, “patient doing well, return in 4 weeks”) supports a 99212. The provider did much more during that visit. None of it is in the note. Under 2027, that gap is real revenue. 

What a 99214 note has to say: 

ACOG’s position: pregnancy is a chronic illness with exacerbation and progression for E/M purposes. The complexity is built in. The note has to reflect it. For a 99214, document the ongoing management of the pregnancy as a condition, the data reviewed with your interpretation, and moderate risk decisions like prescription management or monitoring a condition that could escalate. “Anatomy scan reviewed, normal” is a 99212. “Anatomy scan reviewed, normal four-chamber heart, no CNS abnormality, EFW consistent with dates, AFI normal, counseled patient” is a 99214. 

High-risk patients finally pay for the complexity of their care: 

Under the global model the complex patient and the low-risk patient paid the same. The new model fixes that two ways. Complex visits code at a higher level (99214 / 99215). And more frequent visits equal more claims. For 99215 the note needs the specific complicating diagnosis named, data reviewed with interpretation, the management decision and the reason behind it, and specialist coordination if applicable. 

Same-day procedures and modifier 25: 

Antepartum procedures (NSTs, ultrasounds, amniocentesis, CVS) still bill separately. The E/M visit on the same day is now also billable with modifier 25. The note must independently support the E/M, not just the procedure. 

Three actions this week: 

• Audit twenty random prenatal notes against the 2021 E/M guidelines to set your baseline 
• Rebuild EHR templates to prompt for MDM elements, not for speed 
• Start documentation training in Q3, using providers’ own notes side by side with the corrected version and the dollar difference 

Quick Reference Table:

      Topic                                                                                    What to know

• Deleted codes count                     -      17 codes deleted total 
• Antepartum-only codes                  -       59425, 59426 — deleted Jan 1, 2027
• Global OB codes                                  -       59400, 59510 — deleted Jan 1, 2027 
• New patient E/M range                    -       99202–99205 + modifier TH 
• Established patient E/M range    -       99211–99215 + modifier TH 
• 99214 vs 99213                              -       ~$46 per visit at Medicare rates
• Modifier 25               -       On the E/M when a procedure is also billed same day
• ACOG test date         -September 1, 2026 — recommended start for test claims
• RVU finalization       - CMS proposes July 2026, finalizes November 2026 

RESOURCES BLOCK 

• Save your seat: Live OB/GYN Global Codes Update Webinar (July 7, 2026, 4:00 PM ET) · eligibility.natrevmd.com/obgyn-global-updates-webinar 
• Book a 1:1 with Dr. Signorelli · calendly.com/heather-natrevmd/ 
• Practice Revenue Leak Scorecard · eligibility.natrevmd.com/nrm-revenue-scorecard-v3 
• Payment Posting Audit Checklist · eligibility.natrevmd.com/payment-posting-checklist 
• RECOVER Diagnostic Quiz · natrevmd.com/quiz 
• Series Part 1 (EP188): https://podcasts.apple.com/us/podcast/188-17-ob-codes-just-got-deleted-your-real-deadline/id1624182351?i=1000773393336
• Coming next: EP191 · Phase 2 labor management codes (the codes that have never existed in CPT before) 

Transcript

SPEAKER_01 0:04

All right, so think about this. You have a routine 16-week prenatal note. Maybe you put down blood pressure, fundal height, fetal heart tones, and then maybe you just say, patient doing well, return in four weeks. Now, under the global model, that note was totally fine. But under 2027, that note may cost you money on your prenatal visit. Welcome to Nat RevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signorelli, founder of Nat RevMD. Let's get started. So today I've got a guest with us, Maria Reynoso. I'm going to introduce her here in a second. I'm excited to chat with you guys about all the things prenatal visits and really what you guys need to prepare for the upcoming changes for the global notes. All right, so welcome to the show. Thank you for being here, Maria. I appreciate it.

SPEAKER_00 0:55

Hi Heather. Thank you for having me. My name is Maria. I have been in the OBGYN coding world for about 20 years now. Um, and I'm excited to be here and share some of these upcoming changes with you.

SPEAKER_01 1:08

Awesome. Thank you. So for the listeners, Maria is a director here at our firm and she's been with us for several years. And as she mentioned, she is a master in all things OB. I think if you guys were listening to the episode last week, we talked with Amy. This week we're going to talk with Maria, all of these episodes, so that you guys are prepared for the global changes that are coming in January. I want this to be a I'm prepping now so that January it's not a surprise. And so today we're going to talk all the things about prenatal visits because Maria, you see the denials, like you see the stuff that comes back at and what you're having to do in terms of submission for the for nodes. So just before we even get started with questions, like what happens when you get a denial and like notes come and note requests are coming through? Like, what does that look like on your end from a team perspective?

SPEAKER_00 1:59

So when we get a denial and the nodes are not justifying this code that was billed, is when we really have to reach out to the provider and do some coding education. And if the note is not there to support, we are not going to get paid on this code. So that's very important for providers to meet with the coders and say, hey, these are the elements that you missed to meet the code that was billed. So if I get a denial, I treat that as a red flag. We may have an issue with the coding, with the documentation per se.

SPEAKER_01 2:35

Totally. And do you see, like, are you do you see denials for on the clinic side today too, like your regular ENMs? Are are payers asking for documentation for um like an ENM code just as much as you're seeing them ask for documentation for like an op report? Or do they ask more question more, do they send more requests on the operation side versus the clinic side?

SPEAKER_00 2:59

No, we're definitely seeing medical record requests for ENMs, especially United Healthcare, Blue Shield. They are checking those medical records to make sure that the documentation meets the code that we build. Either it's whether we build the ENM by itself or with a procedure such as an ultrasound, a biopsy. They're making sure that the ENM that we build was reported separately and documented and not bundled with that uh ultrasound or biopsy that was performed on the same date of service. So if that wasn't documented separately, then you're gonna receive a denial for that.

SPEAKER_01 3:37

Got it. And the reason I'm kind of setting the stage here is so we've got these global changes for OB that are coming, right? So in the past, like everything was bundled into the global code. You see a patient for nine months, you drop a global fee at the end. And notes for the clinic piece, were they ever really asked? Or like was it infrequent to have to send notes? Maybe ultrasound maybe would be a different scenario. But did you see note requests for a prenatal visit prior?

SPEAKER_00 4:03

No, very rarely. Maybe when we built like an antipartum only code is when they requested a copy of their prenatal flow sheet, but I never really got requests just for like a prenatal visit. You know, it's only if we're building antipartum only codes and for whatever reason they may want to check the record. Okay, got it.

SPEAKER_01 4:23

So coming January, here soon to us, that's all changing. So maybe go over just a little bit about what codes are changing, right? The antipartum codes that are getting deleted, the OB OB codes that are getting deleted, just high level, so folks who are listening can can remind themselves what's going on. Again, this is our third episode, but I think folks are still trying to soak it all in.

SPEAKER_00 4:43

Of course. So beginning January 1st, 2027, our traditional OB global package is being eliminated. Prenatal visits generally being will be billed with ENM codes, meaning each prenatal visit encounter must stand on its own documentation rather than being global, you know, being bundled into a global code. Our antipartum only codes, so 59425, 59426, will be deleted. The global codes 59400, the 59510 for your C-sections will be deleted. So no bundling of prenatal visits in any form, which means that in 2027, every prenatal encounter will be billed as an E-code. Your new patients, 99202 through 99205, established 99211 through 99215, you will apply a modifier TH on all of them. Framework for telemedicine telehealth visits. The code has to reflect what actually happened at that specific encounter. So it cannot default to one code for every patient every time. You know, the prenatal visit has always felt like a category, but starting 2027, it's a billable event every single time. So that's that's how we have to view it moving forward.

SPEAKER_01 5:57

And that's gonna be that's I think the the this is my my fear. I mean, obviously, we're gonna have to document the labor management and the and the delivery. So obviously those, you know, the same principle applies with regards to being very detailed when it comes to your notes because now it's it's standing alone. Yes, and if they request, you know, medical records, they can say, well, I just want, you know, September 1st's medical record. And that note, if you build a 99215, has to have all the elements of a 992 level five, which is different than what they've traditionally been, you know, documenting for a prerequisite.

SPEAKER_00 6:36

Yes. I mean, if I can tell providers, I mean, your documentation is gonna have to clearly support your problems addressed, your data that you reviewed. So now you have to say labs reviewed ultrasound records, risk management decisions, counseling and coordination of care, the time spent when billing based on time. Now, for high risk pregnancies, that documentation is gonna have to show the complexity. What was your decision making, the review of diagnostic data and management that's gonna support the higher EM level codes, right? So the biggest change of 2027 is gonna be that every prenatal visit should be documented as complete medically necessary EM encounter. It's no longer gonna say patient here for OB visit, fundle high, you know, the weeks, come back in four weeks, right? Yeah, reimbursement is now gonna depend on the documentation for that specific visit rather than the global maternity package.

SPEAKER_01 7:36

It's yeah, and I think for folks, do you think that templates are gonna become a bigger deal for the clinics? Like, can they like I we're starting to, we actually did create some templates that we'll we'll give to folks after the course in July. And so for you guys that are listening, we are doing a deep dive on this July 7th. We're gonna do it live and be able to kind of go over all of these changes. We did create some template draft notes that you guys can use to help up, you know, work with your EMR vendor and be able to get those in. Because I just think it's gonna be more important to get those in if you're not used to doing that.

SPEAKER_00 8:13

Right. And I think for most practices, they may not be used to doing that now, right? Because it it didn't matter if that template was detailed enough because everything's gonna go on a global code. But coming 2027, I mean, your dem, your template, I think most practices are gonna have to revisit that template with your EMR and say, does it support the documentation that I'm gonna need, right? Your assessment, your subject, your subjective objective, your plan so that we meet all the elements of documentation.

SPEAKER_01 8:44

Yeah. Okay, so let's talk about 99214. Like, okay, so I got a patient, their prenatal visit. Like, what how like what are the things I need to document from a 99214's perspective? Or do you think, like, are all pregnancies gonna be 992 or prenatal visits 99214 and five? Or is there gonna be like a difference between like whether or not they can can qualify for 99213 versus a 99214?

SPEAKER_00 9:09

I think there's gonna be a difference. And and a lot of those that difference may come with the complexity of the visit, right? So, first of all, ACOG has stated that pregnancy should be considered a chronic condition with ongoing monitoring and potential progression when applying to EM guidelines. So, as as everyone knows, we also have the data and the risk elements when coding, and we need two of those three elements when selecting the code. So the so, I mean, for pregnancy, most of the time, the complexity is often already in the clinical work. The documentation is simply going to have to demonstrate that work, right? So then to support the 99214, your note should reflect ongoing management of the pregnancy as a medical condition, review and interpretation of clinical data, medical decision based on those findings, moderate risk management, such as prescription medication management, monitoring a condition that could worse without intervention. So it are you monitoring the patient's blood pressure? Are you refilling that blood pressure medication? Is the patient uh diabetic? Are you manage, you know, are you managing that? It's all gonna have to be within your documentation. Again, it's gonna have to support that you did the work versus what we're probably doing now, right? Hypertension return in four weeks, right? Now you're gonna have to expand that note to be able to support that you're managing this. This is a moderate visit.

SPEAKER_01 10:38

So it's not just, hey, labs were reviewed, they were normal. It's like, what labs did you review? What were the results? What did you do about any of them that were not normal? You know, did you do a prescription? Did you do counseling? Uh, because all of that can contribute to being able to take it from a 99214 to possibly a 99215, but you have to tell the story.

SPEAKER_00 10:57

You have to tell the story, right? Especially when reviewing, you know, like your 20-week prenatal visit, right? And you review your anatomy scan, right? So currently you would say anatomy scan reviewed, patient doing well, return in four weeks, right? Under the new guidelines, that would su that would not support, you know, a 99214. It would be a low-level EM, right? What the provider should be doing now is that the note should demonstrate the data that was reviewed and interpreted to the patient, assessment of the symptoms, if any, clinical decision making, the ongoing management of the pregnancy, and whether counseling was done to this patient, right? So discuss in thoroughly what the findings were, what the recommendations were, is there any follow-up with a maternal fetal medicine, et cetera. So, you know, again, currently we're just doing anatomy scan reviewed, return in four weeks, but you're not thoroughly documenting whether there was any problems with the scan, whether there was any f I mean, it's very short documentation. Maybe those findings were within the ultrasound report, but not in the print of floshi itself, right? So moving forward, because all those visits will be billable, is we have to go into documentation.

SPEAKER_01 12:14

Yeah. And it's not just, you know, again, every note has to stand within its own. So even if you addressed them the prior visit, if you don't document that you've addressed it in the next visit and again put that level of detail, then that single billable event that stands on its own may not qualify for the same level of visit in a note that was previous but documented well. So I mean, I think it's like you can't, it's not just one and done. It is every single time. And of course they can bring over notes, you know, but you know, but you gotta be careful doing that and making sure that, you know, you are truly doing what you say you did. Right. Exactly. Okay, so for like, what is your gut? Like, do you feel like this is a good thing for practices who maybe really have complex patients? Because at least then you're able to tell that story, or is it too early to tell? Like, what's your gut on this?

SPEAKER_00 13:09

I think I do think it's a it's a good thing. It can be, right? So yeah, the critical thinking is already happening, right? The doctors are managing these pregnant patients, where again, you know, it's it's complex. Pregnancy is complex. Providers are caring for high-risk OB patients and they're making complex medical decisions every day. They review the data, they interpret the results, coordinate care, manage, they manage significant maternal risks, right? The the thing is now, again, because this is all in a global package, they're not reporting those visits, right? And the documentation was never designated to capture the level of work for reimbursement because we're not billing these visits at currently. So in 2027, the doctors will now be reimbursed for the complexity of work that they're actually performing versus they're not getting that reimbursement now. Right, right.

SPEAKER_01 14:05

Because it was like you just got this average for your global rate, and that is what it is. Now, we have seen some of our practices who've started to play with this type of coding and really adding on EM visits for those complex situations when it warranted a, you know, modifier 25 or something, right? We're seeing a little bit of that. So it's almost like they were preemptively knowing that this was coming, you know, really trying to document the complexity of those patients. And so this is, they were kind of ahead of the curve, I would like to say, don't you think?

SPEAKER_00 14:37

Yes, definitely. And I mean, it a way of seeing this is the again, the complexity already exists, right? The documentation will now need to reflect that. So the the the change is gonna be you're already doing the work, but now you're gonna have to document it to show your work.

SPEAKER_01 14:53

Yeah. Okay. So let's talk about the like what this chain means. I, you know, we kind of just touched on it, but what this change means for practices managing those high-risk patients. So hypertension, preterm history, like obviously under the global model, that, you know, wasn't really something that what they got credit for. Do you think that this is like this? Now they're gonna kind of get credit for that complexity that they were already doing.

SPEAKER_00 15:19

Is that yes, I I definitely do. So I feel that under the traditional global OB model, a practice received essentially the same reimbursement for a high complex pregnancy as it did for a routine low risk pregnancy, right? Because they're not separately reporting these visits. Most practices were not.

SPEAKER_01 15:39

Yeah.

SPEAKER_00 15:39

So the provider was managing gestational diabetes, chronic hypertension, preterm, you know, prior preterm birth, fetal growth restriction, multiple gestations, and they're reimbursed the same amount as a patient with a low risk, right? So they're providing the simply routine prenatal care, the global payment remained the same. So now in 2027, uh the change will be, if I see it this way, is that practices were financially penalized for taking on most medically complex patients, right? So the new E ⁇ M model will change that. There will be two opportunities, in my opinion, it will be that complex visits supports higher level ENM codes, right? So if provider is managing gestational diabetes, hypertension, fetal growth concerns, there is significantly more medical decision making occurring during those encounters. Those visits may appropriately support a 99214, a 99215 when documented correctly. So there is the opportunity for the provider to be reimbursed for the high complex work that they're performing, right? Versus now you're not billing that and you're gonna get paid the same amount. High risk patients are seen more frequently, right? So more visits be mean more billable encounters. Instead of all prenatal care being absorbed into one global single payment, the providers will now be reimbursed for the actual work that they're performing during the pregnancy. So, you know, they're seeing 10 OB visits now versus 17, you're getting reimbursed the same global right, the same global payment, and you're not getting paid. So now with this high risk patients, if you're having to see them more frequent and the complexity is there, the documentation is there, that's a billable event. Right.

SPEAKER_01 17:36

So in that same regard, let's talk a little bit about 99215s, then on what they need in order to hit that 99215. Because I could see a practice, like, yay, they're getting the credit, they're they're seeing the complex patients, they're gonna they can get paid for it. But again, if they mess this note up, you know, five times per pregnancy and don't get that credit for the 99215 times all their OBs, like financially, that could be a hit. So talk to me about 99215.

SPEAKER_00 18:01

So 99215 represents high complexity medical decision making. The documentation will have to demonstrate a severe or significantly progressing condition. So that condition has to be noted as severe. There is a risk for, you know, fetal death, you know, complications, et cetera. Extensive data, review and interpretation, high-risk management decisions, potential risk to maternal or fetal health. OB examples that may support this level of complexity will include pre-eclampsia with worsening symptoms, insulin managed gestational diabetes, severe fetal growth, decreased fetal movement that requires urgent evaluation, cervical shortening, history of preterm labor, hypertension that requires medication adjustments, and close surveillance, right? So those are all high-level complexity care. But again, you will have to document all the elements.

SPEAKER_01 19:05

You have to tell the story because I think it's not just the quick notes, the quick sentence, it's the full evaluation and management.

SPEAKER_00 19:14

Right. I think right now in the in the current prenatal flow sheet, you may see blood sugars reviewed, continue insulin, return in one week, right? This provider may have spent the time, may have performed high-level medical decision making, but the note didn't need to demonstrate it at the current time, right? So moving forward, that note will have to thoroughly demonstrate, you know, reviewed one-week glucose log, demonstrating persistent fasting elevations. I mean, it's gonna have to show a clear, identified, complicated diagnosis, independent review and interpretation of clinical data, prescription medical management, the assessment of the maternal and fetal risk, the ongoing monitoring, and the coordination of care and the treatment planning. So you're already doing the work. It just needs to be documented. Yeah.

SPEAKER_01 20:03

And I think that's where these templates are gonna be in handy because you can, you know, add notes, you can just remind you, okay, yeah, I've got to add that detail, I've got to add that detail is gonna be really key. All right, let's talk same-day procedures and modifier 25. So, what changes here when it comes to prenatal visits, like any NST or an ultrasound?

SPEAKER_00 20:24

So, yeah, so if a patient comes in for an NST, an amnial ultrasound, the difference is that that visit is no longer bundled, right? Most of the time the patients will have questions if the NST was non-reactive, if you know there was some type of malformation in an ultrasound. You do the work, meaning you do the consultation with the patient, but again, it's bundled in your global prenatal care. So moving forward to report both of these services, you will have to append your modifier 25 on your E code, just as you would, you know, with any other procedure. And the documentation is critical, right? The medical record will have to support that this is a true EM service. This is including an assessment, a medical decision making, and management of the pregnancy. A procedure alone is not sufficient to support an EM service, right? The patient came in for an ENST, for an NST and will return in four weeks. I mean, no, you're gonna have to document what was separately discussed with the patient that will support your ENM visit, right? Did anything else come up besides the NST? Was there an abnormal finding that you spend 25 minutes discussing with the patient? Did the patient have any symptoms of a UTI during that visit? That you will report that in a separate ENM. Did you write a prescription? You will have to report that separately and then you will be reimbursed for your ENM visit. But you know, simple, yes, a straightforward NST, you know, may not support. They're just there, they're just there for the NST. Like that'll still be the procedure. And again, it just depends. Is she there for? For her OB visit and her NST, then yes, we just again, the documentation will have to support this as a separate service, separate reimbursement.

SPEAKER_01 22:09

Just like we've been doing with modifier 25s with ENM in a in a in different settings, right, outside of the prenatal visits. But, you know, just like you have a modifier 25 and you have an ENM, you have to be able to separately it has to be separate and significantly identifiable in order to have that ENM stand on its loan, stand on its own compared to whatever else you're billing alongside.

SPEAKER_00 22:30

Right. Yeah. And I think in in pregnancy, there's so many scenarios that can come up, right? Like I can come in for an ultrasound and say, I've had this sinus infection for three weeks, right? Or I've had this UTI symptoms. I've, you know, anything else that may be related, unrelated. Again, the nice part now is you can report that without risking that visit being somehow coming up in your global service later and you're being punished because you build this EM visit during this encounter, right? So the opportunity is there. And I I just think we need to get ready for those changes. And I I do feel that it will be positive for the providers.

SPEAKER_01 23:16

I guess this is our third episode on this topic. I don't want folks to be overwhelmed by what's happening. I think that obviously for the listeners, you guys do EMs. This isn't birth-shattering news. It's just now we're having to document like you do in a, you know, problem visit, like you do for prenatals. So that's just the biggest thing is for you guys just to really start having the conversations with your practice. Have the start, have the conversations with your providers, your physicians, your mid-levels, what is this going to look like in January? And if it were me and this were my practice, I would first look at it on it. So I would pull some random prenatal notes and I would think through, okay, what are the things that people are documenting today? And then how does that compare to visits? If you know that the notes are short and sweet, like you probably could skip that exercise. But then the question is going to be, okay, now I need to build the templates. I need to build out what is the expectation. And if I were the owner of this of a practice, like I'd be having those physicians and mid-levels, everybody be documenting that way for the rest of the year because I still don't think we know. And Amy and I touched on this last time, like I still don't think we really know what to do with people who are pregnant now, right? Pregnant, you know, this fall, but aren't delivering to then to next year, because we're not going to be able to bill for it now because they won't have the codes ready. So, like, I guess we we still don't know the answer to this. I think Amy was gonna submit a question to Right.

SPEAKER_00 24:41

Yeah, we we have some ideas, but we don't know the answer to it yet.

SPEAKER_01 24:45

Yeah. That's that's uh I think that is my biggest thing to help try and get an answer for folks. And again, I, you know, I don't know if we'll be able to, but I think that that's the key is just figuring out like, do folks just count those OB visits for now, which I think is what we're telling practices right now. It's just but to document as if it was an EM just in case we have to go back and then build those ENMs, right? So they need to be documenting that for those pregnancies, even though it hasn't started for next year, right? Right, right. Yeah, okay. Yeah. And then last, as you guys know, we're um doing a course on July on this. I think it's July 7th, 4 p.m. Eastern. We will have the link in the show notes so that you guys can register. Um, even if you can't attend live, come. If you sign up, then you will get the recording, as well as we're gonna be doing some template notes for you guys, as well as a worksheet that you can help model out. And we'll, I'm doing a whole podcast on this modeling and financial review of like how to think through how many patients do I see, how many times do I see a patient? What is my global rate today? What is my EM rate today? Like, how can I model out and make sure that my revenue is not gonna decrease in 2027? Um, because I think that that's gonna be the question on your mind is how is this gonna hit? My hope is that you get the same amount or that you hit a roughly what you're getting today for a global fee. But I think it's important to go through the exercise. So check that. Oh, we'll do that podcast next week. So check it out. So first just want to say thank you to Maria. Really appreciate you being on and just being such a great person to work with every day.

SPEAKER_00 26:20

So thank you for having me here. Thank you. I appreciate it. We have six months to get ready. So there's there's enough time. Uh, just if I could just say audit your documentation, update your templates, train your providers so that everyone is ready come 2027. All right, good plan.

SPEAKER_01 26:37

Thanks, guys. Uh, we'll talk to you next episode.

SPEAKER_00 26:39

Thank you, Heather.