MRT Compliance C-Section/Early Delivery Billing Update

Date Issued: 8/19/2016

MRT Compliance C-Section/Early Delivery Billing Update

Effective July 1, 2016, Medicaid Managed Care will further reduce payment for early elective deliveries without an acceptable medical indication. Claims for elective deliveries prior to 39 weeks, without medical indication, will be reduced by 50 percent. The increased penalty reflects the Medicaid program’s commitment to ensuring appropriate delivery for both mothers and babies.

New York State Medicaid made similar reductions twice since 2013, most recently raising the penalty to 25 percent.

All obstetric deliveries require the use of a modifier (for practitioner claims) or condition code (for hospital claims) to identify the gestational age of the fetus as of the date of the delivery. Failure to submit a modifier or condition code with an acceptable obstetrics delivery procedure code will result in denial of the claim.

PRACTITIONER CLAIMS

Medicaid Managed Care claims submitted by practitioners for obstetric delivery procedure codes 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620 and 59622 require one of the following modifiers:

  • U8 – Delivery prior to 39 weeks of gestation
  • U9 – Delivery at 39 weeks of gestation or later
  • UB – Spontaneous obstetrical deliveries occurring between 37 and 39 weeks gestation

When billing for spontaneous obstetrical deliveries occurring between 37 and 39 weeks gestation, practitioners should report ICD-9 diagnosis code 650 as the primary diagnosis code with the U8 modifier and the UB modifier.

Practitioner claims will be processed in the following manner:

  1. Full payment – Modifier, procedure code and acceptable diagnosis code documented on the claim when delivery less than 39 weeks gestation
  2. 10% reduction – Modifier indicates less than 39 weeks gestation but an acceptable diagnosis code not documented on the claim
  3. Claim denied – No modifier documented on the claim

HOSPITAL CLAIMS

Medicaid Managed Care claims submitted by hospitals for obstetric delivery procedure codes 73.01, 73.1, 73.4, 74.0, 74.1, 74.2, 74.4 and 74.99 require one of two condition codes:

  • 82 – Gestation less than 39 weeks, elective C-section or induction
  • 83 – Gestation 39 weeks or greater
  • 81 – Gestation less than 39 weeks, C-section or induction for medical necessity

Hospital claims are processed as follows:

  1. Full payment – Condition code 83 documented on the claim
  2. Full payment – Condition code 82, procedure code and acceptable diagnosis code documented on the claim when delivery less than 39 weeks gestation
  3. Full payment – Condition code 81, procedure code and acceptable diagnosis code documented on the claim when delivery is 39 weeks gestation
  4. 50% reduction – Condition code 82 indicates less than 39 weeks gestation but an acceptable diagnosis code not documented on the claim
  5. 50% reduction – Condition code 81 indicates less than 39 weeks gestation but an acceptable diagnosis code supporting medical necessity not documented on the claim
  6. Claim denied – No condition code documented on the claim

NYSDOH List of Acceptable Diagnoses Codes