What CPT codes are used for prenatal visits?

Global obstetric codes (59400 vaginal, 59510 cesarean, 59610/59618 VBAC) include all routine antepartum care (13+ visits), delivery, and postpartum. If not using global billing, use 59425 (4-6 visits) or 59426 (7+ visits) for antepartum only. Individual visits outside global care use E/M codes. High-risk conditions may warrant separate E/M with modifier 25.

What documentation is required at each routine prenatal visit?

Document: gestational age/EDD, interval history (fetal movement, contractions, bleeding, leaking fluid, symptoms), vital signs (BP, weight), fundal height (after 20 weeks, cm should approximate weeks), fetal heart rate, urine dipstick (if indicated), review of any pending lab/imaging results, assessment of pregnancy status, and patient education. Brief documentation acceptable for uncomplicated visits.

When can additional E/M services be billed with prenatal care?

Bill separate E/M (with modifier 25) when managing conditions beyond routine prenatal care: gestational diabetes requiring management, chronic hypertension, hyperemesis requiring treatment, preterm labor evaluation, preeclampsia management, or other significant medical problems. Document the separate condition with its own assessment and plan. The problem must be significant enough to warrant its own E/M.

How should high-risk pregnancy documentation differ from routine visits?

High-risk conditions (gestational diabetes, hypertension, multiple gestation, preterm labor, fetal growth abnormality) require: more frequent visits with documented rationale, specific monitoring parameters (glucose logs, BP series, fetal testing), specialist consultations documented, management plan updates, and patient education. Consider whether high-risk conditions warrant separate E/M billing.

What ultrasound documentation is required during pregnancy?

Document: indication for ultrasound, gestational age, fetal number, fetal heart activity, placental location, amniotic fluid volume, and specific measurements based on trimester. First trimester dating uses 76801/76802. Anatomy survey at 18-22 weeks uses 76805/76811 (detailed). Follow-up studies use 76816. Limited/problem-focused uses 76815. Growth studies use biometry with 76816.

Routine Prenatal Visit Template - OB/GYN Pregnancy Care

OB/GYN — Routine Prenatal Visit Template

OB/GYN Obstetrics Updated: 11/7/2025

The Routine Prenatal Visit Template is designed for obstetricians, family medicine providers, and midwives conducting standard prenatal care visits throughout pregnancy. This template documents the essential elements of routine prenatal visits including interval history, fetal assessment, maternal health monitoring, and anticipatory guidance. The template supports appropriate billing for prenatal visits (CPT 59400 for initial, 59425-59426 for subsequent visits) and includes sections for gestational age and estimated due date, interval history including fetal movement, maternal symptoms, and concerns, vital signs including blood pressure and weight, fundal height measurement, fetal heart rate assessment, review of prenatal labs and screening results, assessment of pregnancy status, patient education on nutrition, activity, warning signs, and preparation for delivery, and scheduling of next appointment. This template ensures comprehensive prenatal care documentation while maintaining efficiency for high-volume obstetric practices. Ideal for OB/GYN practices, family medicine practices providing obstetric care, midwifery practices, and community health centers offering prenatal services.

Visit Information

Gestational age: [X] weeks [Y] days
Estimated due date: [Date]
Visit number: [X] of routine visits
Last menstrual period: [Date]

Interval History

Fetal movement: Normal / Decreased / Increased
Maternal symptoms: Nausea, vomiting, fatigue, contractions, bleeding, discharge, etc.
Concerns: [Patient concerns since last visit]
Medications: [Prenatal vitamins, other medications]

Vital Signs

Blood pressure: [BP]
Weight: [Weight] lbs, change since last visit: [+/-X] lbs
Total weight gain: [X] lbs

Physical Examination

Fundal height: [X] cm (consistent with gestational age: Yes / No)
Fetal heart rate: [BPM] (by Doppler / Fetoscope)
Fetal position: [If palpable]
Cervical exam: [If indicated]
Edema: None / Mild / Moderate / Severe (location)

Laboratory/Screening Review

Prenatal labs: [Review results if available]
Ultrasound results: [If recent]
Genetic screening: [Results if available]
Glucose screening: [Results if applicable]

Assessment

1) Pregnancy, [X] weeks gestation

Status: Normal / Complications: [specify]
Fetal status: Reassuring / Concerns: [specify]

2) [Other diagnoses as applicable]

Plan

1) Continue routine prenatal care

Next appointment: [Date] for [type of visit]
Ultrasounds scheduled: [If applicable]
Labs ordered: [If applicable]

2) Patient education: Nutrition, activity, warning signs, preparation for delivery
3) Medications: Continue prenatal vitamins / Adjustments: [specify]

Patient Instructions

Warning signs discussed: [Bleeding, severe pain, decreased movement, etc.]
Return precautions: [When to call or come in]
Next appointment scheduled.

OB/GYN — Routine Prenatal Visit Template

Template