Education & TrainingBadgerCare Plus and Medicaid SSI ProgramsJune 23, 2023

CPT Category II Code Reimbursements

Participating providers with Anthem Blue Cross and Blue Shield (Anthem) can earn an administrative fee for the first prenatal visit and the postpartum visit at $50 per code. The administrative reimbursement per pregnancy is defined in the table found on page two of this letter.

What is a CPT® Category II code?

  • A CPT Category II code provides more detailed information about the clinical service(s) performed.
  • CPT Category II codes are billed similar to the way your office bills for regular CPT codes and are placed in the same location on the claim form.

Benefits of using CPT Category II codes include:

  • A reduction in the need for Anthem to review your medical records by providing more detailed information through your claims submissions.
  • Better tracking and management of member care needs from the use of detailed information provided with the billing of CPT Category II codes.

Next steps you need to take:

  • Review the CPT Category II code billing opportunities and set up your billing system to bill us for the codes when applicable.
  • Report each Category II code with a billing charge of at least $0.01.

If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website for up-to-date contact information, or call Provider Services at 855-558-1443.

Prenatal and Postpartum Care (PPC)

This benefit is eligible once per pregnancy:

  • Incentive payment for prenatal care is $50.
  • Incentive payment for postpartum care is $50 and is limited to one postpartum visit within the fourth trimester or postpartum period.

Initial prenatal care visit

Non-global billing:

  • 0500F: Initial prenatal care visit — Report at the first prenatal encounter with a healthcare professional providing obstetrical care. Report the date of visit and, in a separate field, the date of the last menstrual period (prenatal).
  • Bill with the appropriate evaluation and management code within 30 days of the visit that confirmed the pregnancy (99202 to 99205, and 99211 to 99215).

Global billing:

  • 0501F: Prenatal flow sheet documented in medical record by first prenatal visit. At the minimum, the documentation includes blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery. Report the date of visit and, in a separate field, the date of the last menstrual period.
  • If reporting 0501F prenatal flow sheet, it is not necessary to report 0500F initial prenatal care visit (prenatal)

Postpartum care visit

Non-global billing:

  • 0503F: Postpartum care visit — Make sure the visit is on or between seven and 84 days of delivery. Do not include postpartum care provided in an acute inpatient setting.
  • Bill CPT® with a diagnosis code of Z39.2, and bill CPT II with CPT code 59430.

Global billing:

  • 0503F: Postpartum care visit — Make sure the visit is on or between seven and 84 days of delivery. Do not include postpartum care provided in an acute inpatient setting.
  • Bill CPT with a diagnosis code of Z39.2.

WIBCBS-CD-027963-23, WIBCBS-CD-027962-23