I pulled this from UHC Community policy because it mentions UTIs as being unrelated, which is a similar condition. Just to give a general idea..
B. Services Excluded from the Global OB Package
Per CPT guidelines and ACOG, the following services are excluded from the global OB package (CPT codes 59400, 59510, 59610, 59618) and may be reported separately if warranted:
• First three antepartum E&M visits
• Laboratory tests • Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828). For additional information, see E/M Service with an OB Ultrasound Procedure section.
• Amniocentesis, any method • Amnioinfusion • Chorionic villus sampling (CVS) • Fetal contraction stress test • Fetal non-stress test • External cephalic version • Insertion of cervical dilator more than 24 hours before delivery
• E/M services for management of conditions unrelated to the pregnancy (e.g., bronchitis, asthma, urinary tract infection) during antepartum or postpartum care; the diagnosis should support these services. For further information, please refer to the Non OB Care section of this policy.
• Additional E/M visits for complications or high risk monitoring resulting in greater than the typical 13 antepartum visits; per ACOG these E/M services should not be reported until after the patient delivers. Append modifier 25 to identify these visits as separately identifiable from routine antepartum visits