MRT Compliance C-Section/Early Delivery Billing Update

Revised Date: 12/04/2020
Original Date: 03/16/2018

 

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

 

EmblemHealth’s claims processing rules were updated to remove diagnosis code criteria for claims processed on or after Nov. 9, 2017. EmblemHealth relies 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% for early elective deliveries prior to 39 weeks gestation, retroactively effective Sept. 1, 2017. The additional reduction in 2017 from 2016’s reduction was aimed at keeping both the mother and baby safe through appropriate delivery.

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 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

Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

59510

Routine obstetric care including antepartum care, cesarean delivery, and postpartum care

59514

Cesarean delivery only

59515

Cesarean delivery only; 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

Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); 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

Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care

 

Practitioner claims for obstetrical deliveries, when reported with one of the procedure codes in Table 1, must include one of the following modifiers in Table 2:

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 as well

 

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.

 

Note 1: 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.

Note 2: All elective C-section and induction of labor services require preauthorization.

 

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

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, extraperitoneal, open approach

 

Table 4: The following APR/DRG codes to be used for all deliveries.

If DRG Code is …

The Service is…

540

Cesarean Delivery

541, 542, 560

Vaginal Deliveries

 

Table 5: The following condition codes should be used for C-section and induction of labor for all obstetrical deliveries. These condition codes identify gestational age and whether or not an elective C-section or induction was performed.

Condition Code

Description

81

C-sections or inductions performed at less than 39 weeks gestation for

medical necessity

82

C-sections or inductions performed at less than 39 weeks gestation electively

83

C-sections or inductions performed at 39 weeks gestation or greater

Hospital claims are processed as follows:

 

1.     The following claims are considered payable with no reduction in payment:

Condition Code

Description

81

C-sections or inductions performed at less than 39 weeks gestation for

medical necessity

83

C-sections or inductions performed at 39 weeks gestation or greater

 

2.     Claims billed with condition code 82 are subject to payment reduction:

Condition Code

Description

82

C-sections or inductions performed at less than 39 weeks gestation electively

 

 

3.     Claims denied – C-section and induction of labor claims submitted without any condition code or with condition codes other than 81, 82, or 83 will be denied.

 

            Note: All elective C-section and induction of labor services require preauthorization.

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