MRT Compliance C-Section/Early Delivery Billing Update

Revised Date: 3/16/2018

MRT Compliance C-Section/Early Delivery Billing Update

The New York State Department of Health (DOH) is removing diagnosis code criteria for the processing of claims for elective C-section deliveries and elective induction of labor for Medicaid members.

Retroactively effective as of November 9, 2017, diagnosis code criteria will be removed from our claims processing rules for these claims. EmblemHealth will rely on condition codes reported on institutional claims and the procedure code modifier reported on the practitioner claims to identify elective and medically necessary early deliveries.

All obstetrical deliveries require the use of a modifier (for practitioner claims) or condition code (for hospital claims) to identify the gestational age of the fetus on the date of delivery. If a claim is submitted without a modifier or condition code with an acceptable obstetrics delivery procedure code, the claim will be denied.

Medicaid Managed Care (MMC) will continue to reduce payments by 75 percent for early elective deliveries prior to 39 weeks gestation, retroactively effective September 1, 2017. The additional reduction in 2017 from 2016’s reduction was aimed at keeping both the mother and baby safe through appropriate delivery.

Changes to Billing Guidance from Previous New York State Department of Health Medicaid Updates:

PRACTITIONER CLAIMS

All obstetrical deliveries, whether prior to, at, or after 39 weeks gestation, require the use of a modifier (U7, U8 or U9). If a claim is submitted without a U7, U8, or U9 modifier, as appropriate, with one of the procedure codes in Table 1, the claim will be denied.

Table 1: The following CPT codes represent elective C-section and induction of labor services:
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 obstetrical 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:

Table 2: The following modifiers should be used with the CPT codes in Table 1 for elective C-section and induction services:
Modifier Description
U7 Delivery prior or (less) <39 weeks for medical necessity
U8 Medicaid delivery prior or (less) <39 weeks gestation
U9 Medicaid delivery at or (greater) >39 weeks gestation
UB Spontaneous delivery occurring between 37 and 39 weeks gestation must be billed with modifier U8 also

Practitioner claims will be processed in the following manner:

  1. Full payment – Modifier U7, and procedure code documented on the claim when delivery less than 39 weeks gestation and medically necessary.
  2. Full payment – Modifiers U8 and UB jointly documented on claim with procedure code when spontaneous delivery between 37 and 39 weeks gestation.
  3. Full payment – Modifier U9, and procedure code documented on the claim when delivery is at or greater than 39 weeks’ gestation.
  4. 75% reduction – Modifier U8 only, with procedure code indicates less than 39 weeks gestation.
  5. Claim denied – No modifier documented on the claim.

  • Clams billed with modifier UB must also contain modifier U8. If the claim is billed with modifier UB only, then the claim will be denied.
  • Important Note: All elective C-section and induction of labor services require prior approval.

INPATIENT HOSPITAL CLAIMS

All C-sections and inductions of labor, whether prior to, at, or after 39 weeks gestation, require the use of a condition code (81, 82 or 83). For all spontaneous labor under 39 weeks gestation resulting in a C-Section delivery, please report condition code 81.

Table 3 in this article contains the ICD-10 procedure codes requiring a condition code regardless of gestational age. Table 4 provides this information by DRG codes.

Table 3: The following ICD-10 procedure codes and condition codes represent elective C-section and elective induction of labor services
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 (New code 10/01/2017).
3E0P7VZ Introduction of hormone into female reproductive, via natural or artificial opening.
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, extra peritoneal, open approach.
Table 4: The following APR/DRG codes and condition codes represent elective C-section and elective induction of labor services:
If DRG Code is... Then Service is…
540 Elective C-Section
541, 542, 560 Induction of Labor
Table 5: The following condition codes should be used for elective C-section and induction of labor for all obstetrical deliveries. These condition codes identify gestational age:
Condition Code Description
81 C-Section or induction performed at less than 39 weeks gestation for medical necessity.
82 Gestation less than 39 weeks, Elective C-section/Induction.
83 Gestation at or greater than 39 weeks, Elective C-section/Induction.

Hospital claims are processed as follows:

  1. The following claims are considered payable with no reduction in payment:
    Condition Code Description
    81 C-Section or induction performed at less than 39 weeks gestation for medical necessity.
    83 Gestation at or greater than 39 weeks, Elective C-section/Induction.
  2. Claims billed with condition code 82 are subject to payment reduction:
    Condition Code Description
    82 Gestation less than 39 weeks, Elective C-section/Induction.
  3. Claim denied – No condition code documented on the claim.
  • Important Note: All elective C-section and induction of labor services require prior approval.