#191 Labor Management Is No Longer Invisible

Under the global model, labor management was absorbed into the delivery code. Two hours or twenty-two, same payment. Starting January 1, 2027, the AMA introduces 59080 through 59083, the first dedicated labor management codes in CPT history. The work was always there. Now it gets paid. Dr. Heather Signorelli and Amy Hicks, CPC, COBGC, our AVP of Operations, walk through the codes, the documentation, the corrected delivery code framing, the midnight-spanning labor rule, the multi-provider attribution problem, and the three actions every OB practice should take this quarter. 

Why labor management was invisible: 

Under the global model, the cognitive work of managing labor was absorbed into the delivery code. Practices managing complicated labors (preeclampsia, GDM, category two tracings) have been subsidizing simple deliveries for decades. 

The four new labor management codes: 

59080 (initial day, straightforward) · 59081 (initial day, complex) · 59082 (subsequent day, straightforward) · 59083 (subsequent day, complex). Codes bill per calendar date. One code per date per patient. 

Straightforward vs complex: the six-criteria test: 

All six straightforward criteria must be met: singleton vertex, routine monitoring, no FHR intervention required on that date, normal progression or routine induction without complication, stable medical conditions, no prior cesarean. Any one criterion not met means the labor is complex. Duration of labor alone is NOT complexity unless prolonged labor is formally diagnosed. 

What the complex note has to say: 

Explicitly name the complicating condition. Not just “patient has GDM,” but what about the GDM you managed today. Document MDM across multiple data sources, labs reviewed, monitoring strip interpreted, imaging assessed. Document additional monitoring or intervention beyond standard, what you did and why. Document multi-provider coordination if applicable that date. For 59083 (subsequent day complex), complexity must be re-established for EACH subsequent day. A single admission note does not carry forward. 

Delivery codes (corrected framing): 

The 2027 delivery codes separate vaginal from cesarean, not vaginal from operative. 59431 (vaginal, no prior cesarean) · 59432 (VBAC vaginal) · 59502 (primary cesarean) · 59503 (repeat cesarean). Vacuum and forceps are separately billable add-on procedures. Included in the delivery code: placenta, first and second degree laceration repair, same-day postpartum care. Separately billable add-ons: 59433 (third degree lac), 59434 (fourth degree lac), 59623 (uterine tamponade, new 2027 code), 59504 (hysterectomy with cesarean). 

Midnight-spanning labor (correcting the record): 

A continuous labor encounter spanning midnight is reported as ONE labor management service on ONE of the two calendar dates. The practice decides which date. Inpatient E/M codes (99221 through 99236) do NOT stack with labor management codes. They replace each other. Inpatient E/M applies before labor begins. Once active labor management starts, switch to 59080 through 59083. 

Multi-provider attribution: 

Each provider bills the service they personally performed. The labor management code goes to the provider who managed labor on that calendar date. The delivery code goes to the provider who delivered. If the delivering provider also managed labor on the delivery date, they can bill both. Two failure modes: the miss (no one drops the charge), and the double-bill (both providers drop the same charge). The solution is a daily reconciliation, not monthly. 

Three actions this quarter: 

• Map your call and cross-coverage. Find where charges go unbilled today and where two providers could overlap. 
• Build a daily L and D reconciliation process. Assign ownership. Reconcile before shift end, not at month end. 
• Update EHR labor management templates to prompt for the six criteria, complicating conditions, MDM elements, and same-day decisions. 

 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 2 (EP190): https://podcasts.apple.com/us/podcast/190-every-prenatal-visit-is-now-a-billable-event/id1624182351?i=1000774328121

Transcript

SPEAKER_00 0:05

All right, $0. That is what your practice could be paid next year if you're not paying attention to the global OV changes that are coming. So today we're going to talk all about the things you need to know so that you're coding for these appropriately. Because when that global fee goes away, you aren't going to get paid unless you drop these specific codes. Welcome to NatRefMD, 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 Signarelli, founder of NatRefMD. We also really just want to make sure that you guys are understanding the stuff now, that we're working on our documentation, so that in January this will be old news and you are going to be getting paid and everything is going to go well. So with us today, I'm excited to introduce our AVP for operations across our company. Her name is Amy Hicks, and she's here to explain some of this stuff because this is well above my knowledge and pay grade. So excited to have you, Amy. Amy, well welcome to the show. Thank you for being here. I would love for you to introduce yourself. Tell us your background because you um have had a lot of experience with OB, and I think that's super important for the folks to hear.

SPEAKER_02 1:20

Okay, um, I'm a coder, also specialty OBGYN coder. I have been coding for over 20 years and also in the billing and all across the revenue cycle. But I did start with OB, and I just that's kind of where most of my experience has has lived for the past 20 plus years.

SPEAKER_00 1:39

And it to me, and you correct me if I'm wrong, I find OB billing hard. I'm a pathologist by background, but I feel like OB billing, like when I look at the other billing, and maybe you feel differently because it's been where you've lived, but I find it hard.

SPEAKER_02 1:52

I think it can be hard for if you haven't been coding OB, uh, because it just has different roles than the other specialties do. We have global periods, we have, you know, visits that we just don't get paid for currently. So it it is different um than the other specialties.

SPEAKER_00 2:10

So we have OB practices, many of which are are fairly large. We do the OB coding on the surgery and some delivery side, but the clinic side, we typically don't do the clinic side coding, correct?

SPEAKER_02 2:23

Correct, correct. Usually the providers are coding the clinic side, and then we'll take over for deliveries and surgery.

SPEAKER_00 2:29

Yeah, and I just think with these new changes, the emphasis on coding and documentation in all of the areas is gonna be super important. I really want to emphasize documentation at both on the clinic side as well as some of these labor management codes, which we'll talk through here in a minute.

SPEAKER_02 2:46

Especially before, I mean, a lot of the doctors went and they're doing their global care, we're using an OB flow chart. So they're not having to document each physic. And that's gonna be a big change for the providers moving forward.

SPEAKER_00 2:58

So we are gonna talk today a little bit about some of the updated coding changes. This is part of a larger series. Um I just did one episode that talked about the overall kind of changes that are coming through. So if you haven't listened to that episode, um, that was episode uh 188. And so go check that out before you listen to this one. Today we're gonna talk a little bit about the labor management side of this and making sure that these new codes and the questions around this you guys can understand. You know, I will say we're all kind of trying to figure this out together. So some of these codes are new and some of the rules around how they're gonna be implementing these are new, obviously. Um, there's gonna be things that as they come out, we will update the listeners. So if you haven't subscribed to our podcast or to the newsletter, head on over to our website. Make sure you hit that subscribe button up at the top. Um, and that will just help, you know, make sure that you guys don't miss any information that is necessary. My dad's an OBGYN, he's been an OBGYN for 30 plus years. Those global fees were there. You had a global fee, it was for the nine months of pregnancy. And so these nuances around clear documentation on the prenatal side, on the labor management side, on the postpartum side was a little bit more clinically focused and not billing focused. And as we go into 2027, that's gonna change, right? So those global codes are going away. And we are now gonna be left with figuring out how to how to bill and code for those prenatals. And we'll do a whole episode really on that side of things using those codes. And then you've got the labor management side and then you've got the postpartum side. I I think that there's pros and cons to this. I'll share my thoughts and then Amy, just feel free to disagree or agree. But I, you know, on the pro side, right? Like I think that the idea behind it is that they're trying to capture the complexity of OB patients. Um, but the the flip side of that is if you're getting paid a really good global fee right now and you say see patients less during that period, or you don't document and bill those higher level visits, same with labor management, like you could be in a situation where you're having less revenue, um, even for those complex patients. No, I I agree with you, Heather. I want to go through labor management. So, what does this labor management uh coding system look like? Like what what are you what are you anticipating that the providers need to know as we go into this on the labor management side?

SPEAKER_02 5:28

Currently, under the global um model, labor management has been absorbed into our global delivery codes. It didn't matter if you manage labor for two hours or 22 hours, you receive the same reimbursement. With this shift, AMA introduced new codes 59080 through 59083, specifically to recognize the cognitive and clinical work for managing labor. There are two dimensions to these codes. We have initial day versus subsequent, and within each day, we have straightforward versus complex. There are four codes, and these codes are billed per calendar date, not per hour, not per visit. One code per day per patient. And that's kind of where we're moving to for our labor management.

SPEAKER_00 6:19

Okay, so four codes in initial versus subsequent, straightforward versus complex. And then we've got same date. But if so if if if a patient's being seen for labor, it starts at 11:30 p.m. and it you know crosses that 12 a.m. mark and goes into the next day, it's billed for two codes, correct?

SPEAKER_02 6:40

Now, if now if the if the care is continuous, if the patient started labor at 11:30, you're there with a patient at 11:30, the time it crosses midnight, you're at 1 a.m., 2 a.m., you're only gonna use really one code for that because it's continuous. Now, if the care isn't continuous, then you're gonna use two different codes. Okay.

SPEAKER_00 7:03

Now, if it is continuous, if the doctor's in there the whole time, or what if they leave? And again, you may not know the answer to this, but what if they leave, go manage somebody else and then come back in? Is that discontinuous or does AMA even give us that information?

SPEAKER_02 7:18

We don't have that information. Right now, all we have is that if it's continuous, uh, I'm sure they're gonna put out coding scenarios. Uh the AMA has their QA, and I'm sure we're gonna get more information on that.

SPEAKER_00 7:30

So the other question is what does straightforward versus complex mean? What are folks seeing on turn in terms of coding straightforward versus complex codes?

SPEAKER_02 7:41

Okay, so straightforward, you have to meet six criteria. And the six are we have a single vertex presentation, routine maternal and fetal monitoring, fetal heart rate monitoring that did not require physician intervention on that date, normal progression or routine induction augmentation without complication, stable medical conditions that require no additional management requiring labor on that day, such as wealth controlled hypertension, gestational diabetes, diet controlled. And also the last one is no prior cesarean delivery.

SPEAKER_00 8:22

So, okay, so if those are present, then it's straightforward.

SPEAKER_02 8:26

Yeah, I think we're gonna see more complex um labor management because there's so many patients now, whether you have gestational diabetes, there's the fetal heart rate monitoring requiring intervention. So I just think it's normal. Not I want to say normal, but it'll be common to see complex.

SPEAKER_00 8:42

Yeah, okay. But we still don't have rates for what these are gonna we like practices at least that we manage, nobody knows what these are gonna be reimbursed yet. I mean, I know we've got some RBU numbers and stuff, but how that translates into actual reimbursement, we don't know.

SPEAKER_02 8:57

Yeah, we don't know yet. They haven't, and I haven't seen any payers release um any information on this, so we're not sure exactly what you'll be reimbursed for these. Okay.

SPEAKER_00 9:07

And then um remind me again some of those the complex triggers.

SPEAKER_02 9:11

Okay, yeah, uh common um complex triggers. One is enough to use complex. So we could have category one or three fetal tracing that's requiring physician intervention, um, pre-clampsia with active management, gestational diabetes with active management during labor.

SPEAKER_01 9:29

So I think those are going to be really important for our doctors to document how they're managing the complication. Okay.

SPEAKER_02 9:41

One thing we should add is that lay long labor, uh, the duration of labor does not automatically make it complex. Spending 18 hours on the bedside does not automatically make it complex. The documentation has to reflect the complicating condition.

SPEAKER_00 9:58

So if a patient is in prolonged labor, is it an Just because they spend eight, 10 hours managing labor doesn't mean that it's complex. It's just going to be interesting though. I mean, I I think that it's gonna come down to just like what you said. It's the documentation.

SPEAKER_02 10:14

Yeah, I mean, sometimes you're just in labor that long. You could have a just a normal labor, you're just you know, your contractions, you're not progressing fast. Some people take a long time. And so it can be normal.

SPEAKER_00 10:26

Yeah. So my next question is what does the note actually need to say to support the complex code? And if you were coding these, what are just some highlights that you can make sure that folks make sure that they either have in their templates? Like I think we're gonna have to start doing some template work for this or things that you want to make sure that they're thinking about documenting. I'm thinking straightforward versus complex.

SPEAKER_02 10:51

Okay, for straightforward, you're just gonna have your standard labor documentation, contractions, vital, cervical exam, fetal monitoring. But for complex, we're gonna need to have the physicians explicitly name the condition, not just patient has gestational diabetes, but what did you do to manage the condition today? Your medical decision making is going to need to be documented. Your labs reviews, your monitoring strips interpreted, interpreted, imaging assessed. Um, we're gonna need to know what you did, uh, how you monitored the condition, and what you did. So it's gonna be more documentation required from the providers.

SPEAKER_00 11:33

Yeah, and I can think through maybe you have those noted in the clinic notes, but you're not specifically calling those out in the labor management now that they almost have to stand alone, because we're billing for that delivery code or that labor management code, like it has to stand alone. You're not sending in all nine months of notes, you're sending in that note, you know?

SPEAKER_02 11:52

Right. So each, you know, every date has to stand on its own. So it's just if you did an audit, even with your EM, that date stands alone. I can't pull your visit from a day ago or three weeks ago to support the complexity of your visit today. So it's gonna be very important to note what the complexity is for that date, even if you have already documented it a day before. So each note has to be a standalone. When you're be if you're being reviewed, it has to stand on its own without having to pull any other notes.

SPEAKER_00 12:27

And I see specifically around subsequent days that just as what you're describing, like the notes have to stand alone, that then becomes its own billable event. And so then you're having to justify the complexity of the subsequent day by making sure that you have those notes adequately documented.

SPEAKER_02 12:46

Right. And I know some of you can pull over some notes, but then on that day, you have to also edit and say, you know, still have to add on why it's still complex.

SPEAKER_00 12:58

So the the next question I just want to let's touch on the delivery codes. Um, because there's the the few new delivery codes that um are coming through.

SPEAKER_02 13:07

We had we had our 59514, which just cesarean section, our vaginal delivery of 59409. So those are all going away. Um we will now have um vaginal delivery with no prior uh cesarean, which is a 59431. We'll have vaginal delivery with prior cesarean, which is 59432. Um, we'll have a primary cesarean section, which is going to be CPT 59502, and a repeat cesarean 59503. So what's included in our delivery, placenta delivery, first and second degree laceration still included by the same day. Now we have new codes. We for third and fourth degree lacerations, which have always been billed separately, or some people might have added a 22 modifier to the global codes, but now we have actual new codes we'll be able to bill. We have add-on code 59433 for our third degree laceration and 59434 for fourth degree laceration. So this is good news for us. And a lot of times we've had to file appeals or, you know, sometimes those were tough getting paid. Um, we also have a new code for postpartum hemorrhage. Uh it's going to be 59623. We also have a new code for postpartum hemorrhage of 59623. That's good news for coders. I'm happy about it. We've had, we've been using some unlisted codes and having to send off reports. So hopefully this will make our job as billers a little bit easier. And our hysterectomy add on code is also being deleted. We're going to have a hysterectomy at Tima Cesarean, um, which is 59504, and it's going to be separately available.

SPEAKER_01 14:56

Okay, got it.

SPEAKER_00 14:57

All right. So a lot of changes. Lots of changes. And for those of you guys listening to this in the car while I'm working out, we are going to be having a webinar that we're going to go over all of this stuff. Amy and I will be there together to go through it. Um, and we are doing that on July 7th at 4 p.m. Eastern. And if you register and you're not able to attend live, we get that. We will have the recording that we'll send out. And so you can check the show notes and the show notes will have the link to register. I would just ask, you know, obviously send it to a friend, send it to a colleague. I think that these are really, really major changes as Amy just outlined. And so obviously, nerve-wracking for your peers and colleagues if they don't have the information. I think it's just going to be overwhelming to try and, you know, start learning this all in January, which is why we're here on in June to share this information, at least as as we know it and as we are figuring it out ourselves. All right. So the next question I had, which I think we talked about already, was really just that the idea of like if we have labor spanning different midnight periods, right? So if it like starts before midnight and ends at you know after midnight, I guess you were saying that it has to do with it being continuous versus not continuous.

SPEAKER_02 16:10

Yes, uh a continuous, like like you had mentioned, if the doctor leaves, goes to another room, and then comes back. Is that still one continuous care? So I think we just need a little clarification about that. And we can submit that question to AMA. But if it is, yeah. So they're taking questions online um and then going to answer. So that's the question we can submit.

SPEAKER_00 16:34

Okay, good, good to know. And then the inpatient M codes, we're not reporting those with labor management, right? Like we're doing labor management instead of inpatient EM codes, correct?

SPEAKER_02 16:45

Right. So only time we would probably see an inpatient um code is if it was a planned cesarean. So patient came in, had a planned cesarean. There's really no labor management with that. Um, but you might have to admit the patient, do some workup, maybe patient has a complication. So there might be times where that's justified doing it on a planned cesarean. Because as it is now, and we'll we'll go through that more on our webinar, is that if it's a planned cesarean, you're not you cannot fail labor management.

SPEAKER_00 17:20

Okay, good to know. Um, yes, and the webinar will we'll be able to go into some of this more details, as well as like things that the practices, so you guys listening can start pulling data on and start thinking through, both from planning for teaching your physicians and making sure that they are prepared for this, as well as some uh draft templates that we're starting to put together and a plan of action that you guys can put within your uh practice. So, my last question really has to do with groups that have multiple providers or even multiple providers that maybe are in two different groups. I know in some of our practices, they have hospitals who are delivering the baby. So now if we've got, you know, Dr. Smith managing labor for 12 hours and then Dr. Jones comes on, you know, and does the delivery on the same calendar day, like how is that going to work? I guess it depends on if they're a part of the same group versus not part of the same group. Is that am I thinking about that right?

SPEAKER_02 18:18

So if they're in the same group and Dr. Smith does 12 hours of labor management, Dr. Jones comes in and does the delivery. Both of those are going to be billable in then. So that's good for the providers. I mean, yeah. So that that's a plus for the providers. Um if you're in the same group, you can bill labor management and delivery on the same day. Okay.

SPEAKER_00 18:40

Now, what if, you know, doc what if they're not part of the same group? Well, I guess it doesn't matter if they're part of the same group or not, because again, it's two separate events. It's labor management and then delivery. So it's two separate things going on. Okay, got it. Help me understand this. Okay, so if labor management occurred on the same calendar date as a delivery, the group can build a subsequent day of labor management alongside the delivery code.

SPEAKER_02 19:03

They're all kind of different events. I mean, it's a change of the way we think about um OB and delivery. But yeah, now labor management is a separate event. So a provider, even if you are the same provider delivering, you can also build labor management and either initial or subsequent, whichever it falls under.

SPEAKER_00 19:24

And some things for them to just watch out for is double billing. So two different providers dropping, each dropping labor management charge on the same calendar date. I guess that's that's a risk is if you're covering, say, in 12 hour shifts, but it's on the same calendar date and it's just labor management, we haven't had a delivery yet. But that would be a situation where that could be an issue, right? I guess my question, would that be an issue if they're not in the same group or only if they're in the same group, or do you know?

SPEAKER_02 19:49

So from my understanding right now, and it could change in a couple months, you know, that we're coming out with new roles. But as of right now, if you're in the same group, yes, that's a problem. If you're not in the same group, then you both can bail for labor management. You guys are doing the work. We want them to be paid. So we're not encouraging anyone to expand on documentation. We just want you to document what you're treating, what you're taking care of, what the condition is, what your assessment is, what what is the plan. So, and a lot of times when you the doctors are documenting correctly, we can get to that complex code. So we just want you guys documenting what's happening, and then we can make sure that you're coding the right code or being reimbursed the right code better.

SPEAKER_00 20:36

And I do think that from a workflow perspective for groups that are using other external groups to help manage this labor process, just getting that all down in terms of how that maybe changes billing, especially if they are pay fees, right? For certain like hospitalists or delivery reimbursement to reimburse, but they were billing for the global. So I think just getting that clarity around, okay, now everybody's got to bill what they're actually doing. Again, it should in theory be easier, but you just want to have those conversations, I think, would be my recommendation.

SPEAKER_02 21:09

Yeah, I I totally agree. I mean, we they've been billing this way for a long time. So it's something that's worth discussing and having a plan of around.

SPEAKER_00 21:17

All right. So I'll just give a few key actions that we're asking practices to do. Obviously, register for the webinar. Um, we want you guys to have the information, share it with a friend, just focusing on labor management and delivery only today. And again, we're going to talk prenatal, we're going to talk postpartum here. And we've got uh three more of these episodes that we're gonna do from a podcast plus the webinar. So just want you guys to really map out and think through okay, what do I need to document? What templates can I build out? How do I make sure that all of the physicians and providers, or you just want to get everybody trained and then mapping out that cross-coverage call process, just like I mentioned, we're thinking about, you know, how this is gonna impact revenue documentation and so forth so that you guys have what you need. Um, so we've got, you know, five, six months. Let's figure this out uh together and hopefully these next few episodes. Uh just want to say a thank you to Amy being on. I appreciate you being my right hand on all things practice related and OB related. So I appreciate you being on today. For the listeners, share with a friend and we'll we'll check in the next episode. So thanks again, Amy. Thanks, Heather.