The 5 Most Common Billing Mistakes in OB/GYN And How to Avoid Them
In a busy OB/GYN practice, clinical care takes center stage. But even with a well-functioning front office and a trained billing team, it’s surprisingly easy for revenue to slip through the cracks.
From global maternity billing missteps to overlooked add-on procedures, OB/GYN practices often face revenue losses due to avoidable billing mistakes.
In this article, we uncover the five most common billing mistakes in OB/GYN and provide actionable insights to help your team improve accuracy, reduce denials, and safeguard your financial performance.
1. Incomplete Documentation During Well-Woman Exams
Well-woman visits are foundational in OB/GYN care, but they also come with documentation nuances. One common issue is failing to distinguish between preventive and problem-oriented services provided during the same visit. When not documented clearly, practices often miss out on legitimate reimbursement opportunities.
How to avoid it: Ensure that the provider clearly documents both the preventive service and any separate problem addressed. Use modifier 25 appropriately and make sure supporting documentation justifies both services.
2. Undercoding Out of Audit Fear
Some practices consistently undercode, choosing lower-level evaluation and management (E/M) codes to avoid audits. While the intention is caution, this can lead to substantial underpayment over time.
How to avoid it: Invest in regular coding audits and training. Providers should be confident in coding to the level supported by documentation. Tools like 2021 E/M guidelines can help coders determine the correct levels.
3. Missed Add-On Procedures (Colposcopy, LEEP, Endometrial Biopsies)
One of the common billing mistakes in OB/GYN is failing to bill for add-on procedures due to workflow breakdowns or unclear documentation. For instance, procedures like colposcopy with biopsy or endometrial sampling performed during an office visit are sometimes missed in coding and left unbilled.
How to avoid it: Use procedure checklists to prompt documentation and billing of all services performed. Collaborate with providers to ensure that procedural notes are clear and complete.
4. Incorrect Use of Global Obstetric Billing Codes
OB billing uses a global model that includes prenatal visits, delivery, and postpartum care but not every situation fits neatly into the global package. Mistakes often occur in:
Billing outside the global period (e.g., seeing the patient before 8 weeks gestation)
Transferring care mid-pregnancy
Billing postpartum visits outside the covered range
How to avoid it: Have a clear understanding of what’s included in the global package. When care is transferred, use appropriate codes (e.g., 59425 or 59426). Document all timing-related exceptions clearly.
5. Modifier Confusion (Especially 25 and 59)
Modifier misuse can trigger denials or even audits. Modifier 25 (significant, separately identifiable E/M service) and 59 (distinct procedural service) are both widely used in OB/GYN billing but often incorrectly applied.
How to avoid it: Train your team regularly on modifier logic and documentation requirements. Implement a second-level review for modifier use, especially when bundling rules may apply.
Final Thoughts
Most billing mistakes in OB/GYN don’t stem from negligence, they stem from fast-moving environments, unclear documentation, or outdated workflows. But the impact is real: lost revenue, compliance risks, and reduced efficiency.
At GoSource, we specialize in bringing clarity and control to OB/GYN revenue cycles. Whether you handle billing in-house or partner with a vendor, periodic audits and a strong documentation culture can protect your bottom line.
Want a quick OB/GYN billing checklist or a friendly review of your current process?
About Author
Derick D. Perkins, MBA/MHA, CSPPM
With over 25 years of experience in healthcare leadership, the author has partnered with organizations ranging from small private practices to large medical institutions. His expertise lies in identifying revenue gaps and implementing end-to-end strategies that strengthen the financial health of healthcare providers.
He specializes in optimizing the revenue cycle from billing and A/R management to denial reduction while leveraging automation, AI, and process innovation to drive sustainable improvements. His mission is to help healthcare organizations operate with greater confidence, clarity, and control.
