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.

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.

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.

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

Hospital claims are processed as follows:

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

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

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.