By Tammie W. Lunceford, CMPE, CPC
Global obstetric billing has shaped how practices plan physician compensation, revenue projections and EMR templates, but the current model ends January 1, 2027. When the AMA deletes the current global obstetric package codes (including codes such as 59400 and 59510), maternity care moves to a reimbursement structure based on individual encounters, and care management activities. Practices preparing for the change should be asking direct questions now about whether their current documentation, workflow and coding processes are ready for the 2027 model.
Do Our Physicians Consistently Document E/M Services at the Level Supported by Their Medical Decision-Making?
Many physicians have practiced under a system where the complexity of an individual prenatal visit had little impact on reimbursement. Under the new framework, antepartum visits will be reported using traditional E/M coding. Reimbursement will depend more directly on documentation of medical decision-making, risk assessment and time spent managing the patient’s care.
A routine low-risk prenatal visit, a pregnancy involving chronic hypertension, a patient requiring medication management for gestational diabetes and a pregnancy involving significant behavioral health concerns are not equal encounters. The new guidelines will introduce substantially more granularity. Every visit, every labor management encounter, every postpartum service becomes a potential revenue event requiring accurate documentation, coding, claim submission and payer adjudication.
That creates both opportunity and risk. Organizations that invest in provider education, auditing and workflow redesign could find themselves appropriately reimbursed for complex maternity care that historically went uncompensated.
In chart reviews conducted after other major guideline changes, the documentation often lacks detail about the specific problems addressed and their severity. In many cases, the risk of complications is not detailed enough to support the level of service.
Insurance carriers are already scrutinizing E/M claims based on the severity of the diagnosis. When the service level is high but the diagnosis does not support the level billed, the carrier may automatically downcode the claim and require the provider and billing team to submit documentation supporting the higher level. The new 2027 guidelines for obstetric care will require insurance carriers to set new edits for the coding and guideline changes, as well.
Can Our Existing EHR Workflows Support the New Requirements?
The 2021 E/M guideline changes often required significant EHR template updates. Many practices did not make those changes at the time. Now, the 2027 obstetric billing changes put that issue back in front of practices.
Existing EHR templates may not support the new, higher level of encounter-specific documentation without updates. Practices that wait may be adjusting clinical workflows, coding workflows and revenue cycle processes at the same time.
Are Our Coding Teams Prepared for a Larger Volume of Encounter-Based Coding?
Global obstetric billing reduced the number of separately reported services across maternity care for the past 30 years, but the new model introduces more coding activity. Currently practicing OB physicians and Nurse Practitioners/Nurse Midwives have likely known no other billing or coding process. Each visit, labor management encounter and postpartum service must be documented, coded, submitted and reviewed on its own, which may improve reimbursement for practices caring for high-complexity patients.
A practice caring for patients with diabetes, hypertension, obesity, mental health conditions or maternal-fetal medicine involvement often performs more work than a practice managing mostly low-risk pregnancies. Under the global model, much of that work was absorbed into the same payment.
The new coding framework allows many services to be reported individually, including screening activities, patient education and medically necessary evaluation and management services that were previously included in the global package.
Coding teams will need to translate that documentation into the appropriate E/M and maternity-specific coding. Practices that underestimate the change may see more denials, coding variation and revenue leakage during the transition.
Moving Forward With Obstetric Reimbursement Changes
Practices shouldn’t wait until 2027 to begin asking these questions. Documentation reviews, documentation training, workflow assessments and coding readiness discussions can start now.
Tammie W. Lunceford, CMPE, CPC, is a healthcare consultant with Warren Averett CPAs & Advisors. With over 30 years of experience in healthcare administration, practice operations and medical coding, she advises physician practices, medical groups and healthcare organizations on reimbursement, revenue cycle management, documentation, compliance and operational performance.
Warren Averett’s Physician Practices Group works with physician practices, medical groups and healthcare organizations on operational, financial and compliance matters. The team provides consulting services related to practice operations, reimbursement, coding, revenue cycle management, documentation and workflow improvement to help healthcare organizations evaluate performance and address operational challenges.