Top 7 Billing Challenges in OB/GYN Practices - and How to Overcome Them

 OB/GYN practices face a unique blend of billing challenges due to the wide range of services they provide — from preventive care and surgical procedures to prenatal, delivery, and postpartum care. Navigating this complex landscape requires precise coding, comprehensive documentation, and a deep understanding of payer policies.

Without the right systems in place, practices risk denials, delays, underpayments, and compliance issues — all of which can directly impact the bottom line.

In this article, we explore the top 7 billing challenges in OB/GYN practices and offer practical solutions to help providers and administrators overcome them with confidence.

1. Global Obstetric Billing Confusion

The Challenge:

One of the most misunderstood aspects of OB/GYN billing is the global obstetric package, which bundles routine prenatal care, delivery, and postpartum visits into a single code (e.g., CPT 59400 for vaginal delivery or 59510 for cesarean section). Practices often struggle with:

• Knowing which services are included vs. separately billable
• Handling patients who transfer care mid-pregnancy
• Billing for high-risk pregnancy care that exceeds routine visits

The Solution:

Train your billing team and providers on when and how to break the global package into separate services. For example:

• Use CPT codes 59425 or 59426 for partial prenatal care
• Use modifier -52 for reduced services when needed
• Track additional visits due to high-risk conditions with diagnosis codes that support medical necessity.

Accurate documentation is critical — make sure each visit clearly states whether it falls under routine or high-risk care.

2. Incorrect Use of Modifiers

The Challenge:

Modifiers clarify or alter the meaning of CPT codes, and incorrect usage can result in claim denials or underpayments. In OB/GYN, modifiers are frequently needed for:

• Bilateral procedures (e.g., tubal ligation)
• Multiple procedures performed in the same session
• Unrelated E/M services on the same day as a procedure (e.g., modifier 25)

The Solution:

Provide regular training for coders on modifier usage and conduct internal audits to catch common errors. Use automated billing software that flags incorrect or missing modifiers before claims are submitted.

3. Incomplete or Inaccurate Documentation

The Challenge:

When documentation doesn’t support the billed service, payers are likely to deny or down code the claim. This is especially problematic in OB/GYN, where nuanced patient conditions (e.g., abnormal Pap smears, fibroids, endometriosis) require thorough documentation for higher-level visits or surgical procedures.

The Solution:

Implement documentation templates within your EHR that prompt providers to include key elements. Regularly review provider notes during internal billing audits to ensure compliance and accuracy. Offer ongoing coding education for physicians to reinforce best practices.

4. Preventive vs. Problem-Focused Visits

The Challenge:

Patients often schedule their annual wellness exam and bring up additional concerns during the same visit (e.g., pelvic pain, irregular bleeding). This creates billing confusion: Can both the preventive service and the problem-focused E/M be billed?

The Solution:

Yes — but only when medically necessary and clearly documented. Use:

• CPT 9938x or 9939x for the preventive visit
• CPT 9921x with modifier 25 for the problem-based E/M

Make sure documentation clearly separates the two services. Educate front office staff and patients about potential out-of-pocket costs to avoid surprise billing concerns.

5. Frequent Coding Updates and Payer Policy Changes

The Challenge:

OB/GYN billing is affected by frequent updates to CPT, ICD-10, and payer-specific policies — especially for services like contraception, sterilization, or elective procedures. Falling behind on changes leads to denials or compliance risks.

The Solution:

Subscribe to industry newsletters, payer bulletins, and coding update alerts. Assign a billing lead or compliance officer to monitor changes and update your billing protocols regularly. Partnering with a specialized OB/GYN billing company can also keep your practice ahead of regulatory shifts.

6. Telehealth and Hybrid Visit Billing

The Challenge:

Telehealth gained traction in OB/GYN for services like postpartum check-ins, hormone therapy, or contraceptive counseling. But billing rules for telehealth — especially after the COVID-19 public health emergency — are in flux.

The Solution:

Use the correct CPT codes and place-of-service (POS) codes for virtual visits. For example:

• POS 10 for patient at home
• Modifiers 95 or GT for real-time audio-video visits

Keep a list of payer-specific telehealth policies and ensure proper documentation of time spent, technology used, and patient consent.

7. Insurance Eligibility and Authorization Issues

The Challenge:

Verifying coverage is particularly important in OB/GYN due to services like:

• Elective procedures (e.g., sterilization)
• Maternity care
• Genetic testing and imaging

If eligibility or prior authorization isn’t confirmed, your claims could be denied outright.

The Solution:

Invest in real-time eligibility verification tools integrated with your EHR. Train front-desk staff to check benefits thoroughly and obtain necessary pre-authorizations before scheduling. For maternity care, determine insurance plan rules for global billing and referrals as early as possible.

Final Thoughts: Turning Billing Challenges into Opportunities

OB/GYN billing is intricate, but with the right systems and team in place, these challenges become opportunities for improvement and growth. By prioritizing documentation, training, compliance, and technology, your practice can reduce denials, increase reimbursements, and provide better patient experiences.

Here’s what to do next:

• Regularly review your denial trends
• Offer refresher training for your billing and clinical team
• Consider outsourcing to a specialized OB/GYN billing service if internal capacity is limited

Need help overcoming billing challenges in your OB/GYN practice? Contact us today to learn how our experts can streamline your revenue cycle and boost your bottom line.