MRT Compliance C-Section/Early Delivery Billing Update

Date Issued: 9/1/2017

MRT Compliance C-Section/Early Delivery Billing Update

Starting on September 1, 2017, Medicaid Managed Care (MMC) will reduce payments by 75% for early elective deliveries prior to 39 weeks gestation. This additional reduction over last year is aimed at keeping both the mother and baby safe through appropriate delivery.

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.

Billing Guidance from New York State Department of Health May 2016 Medicaid Update:

PRACTITIONER CLAIMS

Elective C-sections or inductions of labor, when reported with one of the procedure codes in Table 1, whether prior to 39 weeks gestation or after 39 weeks gestation, require the use of a modifier (U8 or U9). If the delivery is the result of a spontaneous labor after 39 weeks (and does not require augmentation of labor or result in a C-section), no modifier is required and the procedure code is not included in Table 1.

Claims submitted by practitioners for the obstetric delivery procedure codes included in Table 1 will require a modifier.

Spontaneous labor resulting in a delivery less than 39 weeks gestation

If the delivery occurs prior to 39 weeks gestation and the delivery (C-section or vaginal) occurs as a result of spontaneous labor, report modifier U8 and the claim will pay in full if the following ICD-10 diagnosis code is reported in The Primary Position: O60.10X0 – Preterm labor with preterm delivery.

Table 1: CPT Procedure Codes Requiring a Modifier
CPT Procedure Code Description
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care.
59409 Vaginal delivery only (with or without episiotomy and/or forceps).
59410 Including postpartum care.
59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care.
59514 Cesarean delivery only.
59515 Including postpartum care.
59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps).
59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps).
59614 Including postpartum care.
59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery.
59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery.
59622 Including postpartum care.

Practitioner claims for obstetric deliveries, when reported with one of the procedure codes in Table 1, must include one of the following modifiers:

  • U8 – delivery prior to 39 weeks gestation
  • U9 – delivery at 39 weeks gestation or later

Failure to include a U8 or U9 modifier, as appropriate, on a claim will result in denial of the claim.

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. F75% reduction – Modifier indicates less than 39 weeks gestation but an acceptable diagnosis code not documented on the claim.
  3. FClaim denied – No modifier documented on the claim.

INPATIENT HOSPITAL CLAIMS

Elective C-sections or inductions of labor, whether prior to 39 weeks gestation or after 39 weeks gestation, require the use of a condition code (81, 82, or 83). If the delivery is the result of a spontaneous vaginal delivery after 39 weeks (and does not require augmentation of labor, result in a C-section delivery, or require artificial rupture of membranes), no condition code is reported on the claim as the procedure code is not included among those that require condition codes.

Table 2 in this article contains the ICD-10 procedure codes requiring a condition code regardless of gestational age.

Note: Only obstetrical deliveries involving either an induction of labor/augmentation of labor, artificial rupture of membranes, or C-sections require the use of a condition code. All other vaginal deliveries resulting from a spontaneous labor do not require the use of a condition code.

If any of the ICD-10 procedure codes in Table 2 are reported following spontaneous labor, please report with ICD-10 diagnosis code O60.10X0 (Preterm labor with preterm delivery, unspecified trimester, not applicable or unspecified) in the primary position as the principal diagnosis.

Note: Do not report code O60.10X0 if procedures listed in Table 2 have been completed as an elective induction of labor prior to 39 weeks gestation.

Failure to report a condition code (81, 82, or 83) for those ICD-10 procedure codes included in Table 2 will result in the claim being denied.

Condition Codes:

  • Condition code 81 - C-sections or inductions performed at less than 39 weeks gestation for medical necessity.
  • Condition code 82 - C-sections or inductions performed at less than 39 weeks gestation electively.
  • Condition code 83 - C-sections or inductions performed at 39 weeks gestation or greater.
Table 2: ICD-10 Procedure Codes Requiring a Condition Code
ICD-10 Procedure Code Description
10900ZC Drainage of amniotic fluid, therapeutic from products of conception, open approach.
10903ZC Drainage of amniotic fluid, therapeutic from products of conception, percutaneous approach.
10904ZC Drainage of amniotic fluid, therapeutic from products of conception, endoscopic approach.
10907ZC Drainage of amniotic fluid, therapeutic, from products of conception, via natural or artificial opening.
10908ZC Drainage of amniotic fluid, therapeutic from products of conception, via natural or artificial opening endoscopic.
0U7C7ZZ Dilation of cervix, via natural or artificial opening.
3E030VJ Introduction of other hormone into peripheral vein, open approach.
3E033VJ Introduction of other hormone into peripheral vein, percutaneous approach.
3E0P7GC Introduction of other therapeutic substance into female reproductive, via natural or artificial opening
10D00Z0 Extraction of products of conception, classical open approach.
10D00Z1 Extraction of products of conception, low cervical, open approach.
10D00Z2 Extraction of products of conception, extraperitoneal, open approach.

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. 75% reduction – Condition code 82 indicates less than 39 weeks gestation but an acceptable diagnosis code not documented on the claim
  5. 75% 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