New Policy and Billing Requirements for Elective Delivery (C- Section and Induction of Labor) before 39 weeks without Medical Indication
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1 New Plicy and Billing Requirements fr Elective Delivery (C- Sectin and Inductin f Labr) befre 39 weeks withut Medical Indicatin Backgrund: As stated in the enclsed June 2013 New Yrk State Department f Health Medicaid Update, the New Yrk State Medicaid Redesign Team Basic Benefit Wrk Grup s final recmmendatins include reducing payments fr elective C-sectin deliveries and inductins f labr under 39 weeks gestatin unless there is a dcumented medical indicatin. Evidence suggests that infants delivered prir t 39 weeks have an increased chance f cmplicatins and duble the mrtality rate f infants delivered at full term. Risks t the mther include an increased risk f infectin, injury t ther rgans, infertility, anesthesia cmplicatins and difficulty with breast-feeding. Cverage Decisin: NYS Medicaid will reduce payment fr elective deliveries (C-sectins and inductin f labr) befre 39 weeks withut an acceptable medical indicatin. The effective date f the payment plicy belw fr all applicable deliveries reimbursed by UnitedHealthcare Cmmunity Plan and Family Health Plus is Jan.1, Plicy: All bstetric deliveries will require the use f a mdifier r cnditin cde t identify the gestatinal age f the fetus as f the date f the delivery. Failure t prvide a mdifier/cnditin cde with the bstetric delivery prcedure cde will result in denial f the claim. Enclsed is the Plicy & Billing Guidance prvided by New Yrk State Medicaid with the cdes fr yur reference. As a reminder, all claims payments are subject t the member s eligibility n the date f service and applicable authrizatin requirements. Dc#: UHC2784a_
2 Elective Delivery (C-Sectin and Inductin f Labr) < 39 Weeks withut Medical Indicatin In respnse t Medicaid Redesign Team (MRT) Initiative 5402F BACKGROUND The New Yrk State (NYS) MRT Basic Benefit Wrk Grup s final recmmendatins include reducing payments fr elective C-sectin deliveries and inductins f labr under 39 weeks gestatin unless a dcumented medical indicatin is present. Evidence suggests that infants delivered prir t 39 weeks have an increased chance f cmplicatins and duble the mrtality rate f infants delivered at full term. Maternal cncerns include an increased risk f infectin, injury t ther rgans and infertility, as well as anesthesia cmplicatins and difficulty with breastfeeding. COVERAGE DECISION POLICY & BILLING GUIDANCE NYS Medicaid will reduce payment fr elective deliveries (C-sectin and inductin f labr) < 39 weeks withut an acceptable medical indicatin. The fllwing plicy will be effective fr fee-fr-service Medicaid recipients beginning July 1, System edits may nt be in place n July 1, Hwever, plicy implementatin will be retractive t the July 1, 2013 start date. The effective date fr Medicaid Managed Care and FHPlus enrllees is Octber 1, The payment plicy belw is als applicable t all deliveries reimbursed by Medicaid Managed Care and FHPlus plans. Prviders shuld check with each health plan fr implementatin details. POLICY All bstetric deliveries will require the use f a mdifier r cnditin cde t identify the gestatinal age f the fetus as f the date f the delivery. Failure t prvide a mdifier/cnditin cde with the bstetric delivery prcedure cdes listed belw will result in the claim being denied. -cntinued- June 2013 New Yrk State Medicaid Update 6 P a g e
3 PRACTITIONER CLAIMS Effective July 1, 2013, Medicaid fee-fr-service claims (Octber 1, 2013 fr Medicaid Managed Care and FHPlus claims) submitted by practitiners fr bstetric delivery prcedure cdes 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, r will require a mdifier. Practitiner claims fr bstetric deliveries must include ne f the fllwing mdifiers. Failure t include ne f the tw mdifiers belw n a claim will result in denial f the claim. U8 - Delivery prir t 39 weeks f gestatin U9 - Delivery at 39 weeks f gestatin r later Practitiner claims will be prcessed in the fllwing manner: 1. Full payment mdifier included n claim, acceptable diagnsis cde is dcumented when a delivery is <39 weeks gestatin % reductin mdifier indicates <39 weeks gestatin and an acceptable diagnsis cde is nt dcumented. 3. Claim denied n mdifier dcumented n claim. System edits t deny payment fr claims withut a mdifier r t reduce payment fr medically unnecessary early deliveries will nt be in place n July 1 but will be implemented at a later date. Physician claims fr deliveries perfrmed n r after July 1, 2013, will be reprcessed autmatically by emedny when the system changes are implemented and previusly paid claims will be adjusted accrdingly. Physicians shuld use the apprpriate mdifiers fr dates f service n r after July 1, 2013, t avid payment denials. HOSPITAL CLAIMS Effective Octber 1, 2013, NYS Medicaid claims submitted by hspitals fr bstetric delivery prcedure cdes 73.01, 73.1, 73.4, 74.0, 74.1, 74.2, 74.4, and will require a cnditin cde. On Octber 1, 2013, the Natinal Unifrm Billing Cmmittee (NUBC) will add tw new cnditin cdes t the UB data set fr hspitals t utilize when submitting inpatient institutinal claims. After this date, all claims submitted by hspitals (institutinal claim) will be required t reprt the apprpriate cnditin cde when submitting inpatient claims fr bstetric deliveries. Althugh the cnditin cdes will nt be available t hspitals until Octber 1, 2013, NYS Medicaid reserves the right t reduce fee-fr-service payment t hspitals by 10% fr deliveries n r after July 1, 2013 (Octber 1, 2013 fr Medicaid Managed Care and FHPlus), if it is determined that the elective early delivery was nt medically indicated. -cntinued- June 2013 New Yrk State Medicaid Update 7 P a g e
4 UBC Cdes effective Octber 1, 2013: 82 Gestatin less than 39 weeks, elective C-sectin r inductin 83 Gestatin 39 weeks r greater Hspital claims will be prcessed in the fllwing manner: 1. Full payment Cnditin cde present, acceptable diagnsis cde is dcumented when delivery is <39 weeks gestatin % reductin Cnditin cde indicates <39 weeks gestatin and an acceptable diagnsis cde is nt dcumented. 3. Claim denied N cnditin cde dcumented n claim. The fllwing payment structure will be implemented fr hspital inpatient claims when these ICD-9 prcedure cdes are reprted n the claim: 73.01, 73.1, 73.4, 74.0, 74.1, 74.2, 74.4, and N cnditin cde reprted deny claim. Cnditin cde 82 if this cnditin cde is reprted withut an acceptable diagnsis cde, reduce claim by 10%. Cnditin cde 83 if this cnditin cde is reprted, pay claim in full. Gestatinal age f the fetus shuld be determined t be at least 39 weeks. Claims submitted by practitiners and hspitals fr deliveries perfrmed at < 39 weeks gestatin withut an acceptable medical indicatin will be reduced by 10%. Cnfirmatin f term gestatin can be determined by the fllwing: An ultrasund measurement at less than 20 weeks f gestatin supprts gestatinal age f 39 weeks r greater. Fetal heart tnes have been dcumented as present fr 30 weeks by dppler ultrasngraphy. It has been 36 weeks since a psitive serum r human chrinic gnadtrpin pregnancy test result. -cntinued n next page- June 2013 New Yrk State Medicaid Update 8 P a g e
5 Acceptable Diagnses fr Elective Delivery <39 Weeks Indicatins ther than thse stated belw may als be apprpriate with clinical justificatin (see Appeal Prcess belw). Diagnses Placenta Abruptin Placenta Previa w/ hemrrhage Placenta Previa-w/hemrrhage Cde Vasa Previa/cmplete placenta previa Prir vertical r T incisin cesarean sectin Prir mymectmy necessitating cesarean delivery Hypertensin, cmplicating pregnancy, childbirth, and the puerperium. Preeclampsia, Eclampsia, Chrnic hypertensin Early Onset f Delivery, Unspecified Early Onset f Delivery, Delivered Early Delivery with PP Diabetes Mellitus cmplicating pregnancy Chriamniitis Pre-Labr Rupture f Membranes Prlnged Rupture f Membranes Maternal Diseases/cnditins, nt limited t: Liver Chlestasis f Pregnancy Cngenital cardivascular Other cardivascular Renal Disease Maternal malignancies Herpes Gestatinis , , , , , , , , , , , , , , , , , , , , , , , , , , Antiphsphlipid Syndrme , Rare maternal trauma Including, but nt limited t: Maternal death POLICY & BILLING GUIDANCE Labr, spntaneus , Severe fetal grwth restrictin Fetal Cmprmise Abnrmal fetal heart rate June 2013 New Yrk State Medicaid Update -cntinued- 9 P a g e
6 Acceptable Diagnses fr Elective Delivery <39 Weeks (cntinued) Diagnses Majr Anmaly CNS malfrmatin-deliv Chrms abnrmality-deliv Damage d/t virus-deliv Damage d/t disease-deliv Damage d/t drug-deliv Radiat fetal damage-deliv Abnrm nec-unspecified Gastrschisis Multiple gestatin Twins Triplet pregnancy Quadruplet pregnancy Other specified multiple gestatin, delivered w/r withut mentin f antepartum cnditin Olighydramnis Plyhydramnis Cde Macrsmia Isimmunizatin frm ther & unspec bld-grup incmpatibility Malpresentatin f fetus Unstable Lie Multiple gestatin with malpresentatin f ne fetus r mre Fetal Demise (singletn still birth) , , , (multiple gestatin with ne r mre still birth) CLAIM DENIALS If a practitiner and/r hspital claim is denied fr payment due t lack f an apprpriate cnditin cde r mdifier, please resubmit the claim with the apprpriate mdifier r cnditin cde. Questins shuld be directed t the emedny Call Center at (800) Questins regarding Medicaid fee-fr-service plicy shuld be directed t the Divisin f Prgram Develpment and Management at (518) Questins regarding MMC/FHPlus reimbursement and/r dcumentatin requirements shuld be directed t the enrllee s MMC r FHPlus plan. -cntinued- June 2013 New Yrk State Medicaid Update 10 P a g e
7 APPEAL PROCESS A 10% reductin in either the hspital inpatient claim r a practitiner claim may be appealed thrugh the fllwing prcess: 1) Medicaid fee-fr-service practitiners r hspitals may request an appeal by cntacting the Divisin f Prgram Develpment and Management at (518) ) Medicaid fee-fr-service appeals will be referred t Island Peer Review Organizatin (IPRO) fr review. 3) A decisin will be rendered by IPRO fllwing clinical review. Prviders will be asked t submit a written clinical justificatin, alng with a medical recrd. If the appeal is upheld, n additinal payment will be made. If the appeal is verturned, the claim will be readjudicated and payment will be restred t 100%. 4) If a prvider wishes t appeal a payment reductin made by a Managed Care Plan, they shuld cntact that Plan t get details n the appeal prcess. Practitiners and hspitals are respnsible fr ensuring that the cdes (and mdifiers when applicable) submitted fr reimbursement accurately reflect the diagnsis and prcedure(s) that were reprted. Pst payment reviews may be cnducted by the Office f the Medicaid Inspectr General (OMIG) and/r thrugh a Medicaid-funded utilizatin management cntractr, as apprpriate (pursuant t 18 NYCRR 504.8) n adjudicated claims. Medical recrds must be maintained by prviders fr a perid f nt less than six years frm the date f payment. June 2013 New Yrk State Medicaid Update 11 P a g e
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