👩⚕️ OB/GYN Coding: What You Need to Know
OB/GYN coding (Obstetrics and Gynecology coding) involves assigning the correct CPT®, ICD-10-CM, and sometimes HCPCS codes for medical services related to pregnancy, childbirth, and women’s reproductive health.
It’s an essential part of ensuring proper reimbursement, accurate medical records, and compliance with healthcare regulations.
🧩 1. What OB/GYN Coding Covers
OB/GYN coding includes two main areas:
Area Description
Obstetrics (OB) Care related to pregnancy, labor, delivery, and postpartum services.
Gynecology (GYN) Care related to the female reproductive system — exams, procedures, and surgeries not involving pregnancy.
⚕️ 2. Common Code Sets Used
Code Set Purpose
CPT (Current Procedural Terminology) Used for reporting services and procedures (e.g., exams, deliveries, surgeries).
ICD-10-CM (Diagnosis Codes) Used for reporting diagnoses and medical conditions.
HCPCS (Healthcare Common Procedure Coding System) Used for supplies, medications, or certain additional services.
🤰 3. Obstetric (OB) Coding Overview
Obstetric coding can be complex because it covers the entire maternity cycle — from conception to postpartum care.
Key areas include:
Antepartum care – prenatal visits and check-ups
Delivery – vaginal or cesarean
Postpartum care – care after delivery (usually up to 6 weeks)
Common CPT codes:
Service CPT Code
Routine obstetric care (global package, vaginal delivery) 59400
Routine obstetric care (cesarean delivery) 59510
Vaginal delivery only (no antepartum or postpartum care) 59409
Cesarean delivery only 59514
VBAC (vaginal birth after cesarean) 59610 (with routine care) / 59612 (delivery only)
Example:
A patient receives complete prenatal care, a vaginal delivery, and postpartum care — you would code 59400 (global OB package).
🩺 4. Gynecology (GYN) Coding Overview
Gynecological services include annual exams, contraceptive management, menstrual disorders, and surgical procedures.
Common CPT codes:
Service CPT Code
Preventive exam (new patient, 18–39 years) 99385
Preventive exam (established patient, 18–39 years) 99395
Pap smear collection (added to preventive visit) Q0091
Insertion of intrauterine device (IUD) 58300
Removal of IUD 58301
Endometrial biopsy 58100
Dilation and curettage (D&C) 58120
🧠 5. ICD-10-CM Codes for OB/GYN
Obstetric diagnosis codes (start with “O”):
O00–O9A – Pregnancy, childbirth, and the puerperium
Example:
O09.529 — Supervision of elderly multigravida
O80 — Encounter for full-term uncomplicated delivery
Gynecologic diagnosis codes:
N codes – Disorders of the genitourinary system
Example:
N92.0 — Excessive menstruation at puberty
N80.0 — Endometriosis of uterus
Z codes – Routine exams or screenings
Example:
Z01.419 — Gynecological exam (routine, without abnormal findings)
Z12.4 — Screening for malignant neoplasm of cervix
🧾 6. The Global OB Package
The global maternity package includes:
All routine prenatal visits
Delivery
Postpartum care (up to 6 weeks)
Not included:
Laboratory tests
Ultrasounds
Complicated visits (e.g., high-risk pregnancy)
Hospital admissions unrelated to routine care
If a provider only performs part of the care (e.g., delivery only), use delivery-only codes (e.g., 59409 or 59514).
🩹 7. Modifiers in OB/GYN Coding
Modifiers clarify that a procedure or service was altered in some way. Common examples:
Modifier Meaning Example
-25 Significant, separately identifiable E/M service on the same day as another procedure Preventive visit + problem-oriented visit
-59 Distinct procedural service Two procedures performed at different sites
-26 Professional component only Ultrasound interpretation
-TC Technical component only Ultrasound equipment use
⚠️ 8. Common OB/GYN Coding Mistakes
❌ Using global delivery codes when only partial services were provided
❌ Forgetting to bill separately for labs, ultrasounds, or non-routine visits
❌ Using the wrong diagnosis code (e.g., Z01.419 vs. N89.8)
❌ Not linking the correct ICD-10 code to the CPT procedure
🧩 9. Documentation Tips
✅ Record dates for all prenatal visits and deliveries
✅ Note whether care was routine or high-risk
✅ Include procedure details (e.g., delivery type, instruments used)
✅ Clearly separate preventive and problem-oriented services
🏁 Summary
Area Examples
Obstetric CPT Codes 59400 (routine OB care), 59510 (C-section)
Gynecologic CPT Codes 99395 (preventive exam), 58300 (IUD insertion)
ICD-10 Codes O80 (uncomplicated delivery), Z01.419 (routine GYN exam)
Common Modifiers -25, -59, -26, -TC
Global Package Includes Antepartum + Delivery + Postpartum care
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