The American Medical Association is overhauling how U.S. doctors report and bill for pregnancy services, bulldozing the current system of bundled payments and replacing it with more granular, itemized codes next year.
The changes, shared exclusively with Healthcare Dive, could help improve poor maternity health outcomes in the U.S. But it’s also an acquiescence to specialty groups, which have long lobbied the powerful medical association that modern obstetric services are more complex than the current coding system is able to reflect.
The move also represents a step back for value-based care, and could incentivize OB-GYNs and other doctors to provide unnecessary medical services at a time of skyrocketing health spending.
But the changes shouldn’t result in OBGYNs, nurse-midwives or other maternity care specialists bringing in more revenue, according to the AMA, which argues the new coding system will benefit the entire healthcare industry.
Fresh maternity codes
Historically, common procedural terminology, or CPT, codes for pregnancy care have been global codes bundling all of the medical services an expectant mother receives across the different phases of a pregnancy.
But the AMA is deleting the global codes, and swapping them out for a combination of evaluation and management codes and new code categories capturing specific stages in a pregnancy, such as labor management, the association told Healthcare Dive.
The move, which will go into effect on Jan. 1, 2027, represents a sea change for maternity coding. Despite some tweaks in 2009, America’s underlying code structure for pregnancy services has been in place since the mid-1990s, according to Dr. John Horton, the vice chair of clinical affairs for the Department of Gynecology and Obstetrics at Emory Healthcare, an academic medical system in Georgia.
But maternity care has changed drastically over the last three decades. Increasingly, pregnancy services are delivered by teams of medical professionals across the different phases of a pregnancy — antepartum, labor management, delivery and postpartum. More provider types are involved, such as certified nurse midwives, laborists and postpartum specialists, and the care they provide is often more complex than what the global codes include.
Patients are also more likely to bounce between different sites of service, like high-risk patients being transferred from rural hospitals to better equipped facilities.
Such transitions are difficult to capture under global codes, according to Dr. Daniel Halevy, an executive at New York nonprofit insurer Healthfirst.
“Things have changed over the last 30 years in terms of how women are getting maternity care, how it’s being delivered — no pun intended — by OB-GYNs,” Halevy said.
The AMA convened a workgroup two years ago to evaluate its maternity care codes, responding to specialty societies like the American College of Obstetricians and Gynecologists that called on the powerful medical association to update how the CPT system tracks pregnancy services.
The changes, which the AMA will officially roll out Monday in a webinar for insurers, are the culmination of that group’s “incredibly deliberate” process involving input from doctors, nurses, family medicine practitioners, radiologists and other providers, according to Horton, who participated in the workgroup.
The AMA has issued CPT codes for more than six decades, providing a standardized system for reporting medical services. The codes are deeply engrained into the bedrock of the U.S. healthcare system — used to reimburse providers, evaluate medical utilization, conduct research and more.
The AMA’s CPT Editorial Panel, a group of clinical experts appointed by the powerful medical association’s board, officially publishes codes for the upcoming year in the fall.
But the CPT Editorial Panel chose to release the new maternity codes for 2027 early given the mammoth task of implementation, Halevy, a member of the panel, said.
It could take insurers and their vendor partners months to pivot to the new maternity codes, given how deeply the current global codes are woven into healthcare reporting and billing systems.
But along with benefiting doctors in the space, the coding changes should be benefit payers and patients, too, Halevy argued.
Global codes are normally billed when a baby is delivered, which can keep insurers in the dark about their members’ pregnancies. The new codes should give insurers more information, including when a member gets pregnant, that could help them ensure expecting mothers get adequate prenatal care, or know if mothers had complications during delivery that could necessitate follow-up services, according to Halevy.
Better data collection and care coordination could also help stitch up gaps in the U.S. healthcare system that contribute to the nation’s poor maternal health. In 2023, the U.S. maternal mortality rate was nearly 19 maternal deaths for every 100,000 live births, well above that of other developed counties.
That’s despite more than 80% of pregnancy-related deaths being preventable, according to the Centers for Disease Control and Prevention.
Pivoting back to fee-for-service
However, there are some benefits to the current system of global codes.
It may be simpler for providers to code once for a suite of services than for each service as it occurs, especially during a time of sky-high administrative burden on U.S. doctors.
Moreover, the global codes align towards the industry’s larger shift towards value-based care, instead of rewarding doctors based on the quantity of the services they provide. Moving from bundled services back to an itemized, fee-for-service payment structure could incentivize doctors to overutilize maternity care in order to get higher reimbursement.
But maternal care specialties shouldn’t be paid more as a result of the changes, according to Robert Mills, a spokesperson for the AMA. That’s because the AMA crafted the modernized codes to be budget-neutral, to comply with Medicare requirements for annual changes in payment policy.
Overutilization is “always going to be a theoretical outcome,” Halevy said. But “the benefits outweigh the risks.”
Still, there’s rising discontent among some politicians and healthcare stakeholders with the AMA having sole discretion over CPT codes — a discontent that could be exacerbated by the association’s unilateral overhaul of the nation’s maternity coding structure.
The AMA has argued that its status as the biggest association of doctors and medical students gives it the scale and expertise to determine definitions for medical services, and that there are checks and balances in place to ensure it’s reflecting the needs of the entire healthcare community.
But there’s a powerful conflict of interest, critics say, in a physician association having so much influence in determining how physicians get paid. Along with the CPT codes being used to document services and submit claims to private insurers, the CMS uses the codes, along with recommendations from a panel of AMA doctors, to decide how much Medicare will pay for medical services.
Moreover, issuing codes is lucrative for the AMA, as companies that use them have to pay license fees.
The Trump administration may be interested in wresting control of medical billing away from the AMA, the Washington Post reported in 2024. Though the HHS has not taken concrete steps to kill the AMA’s influence yet, the CMS’ Medicare payment rule last year was viewed as a small step toward limiting the association’s input.
