Anthem Medicaid s Early Elective Delivery Reimbursement Policy Effective July 1, 2014

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1 Serving Hoosier Healthwise and Healthy Indiana Plan Anthem Medicaid s Early Elective Delivery Reimbursement Policy Effective July 1, 2014 This Provider Bulletin is to notify you of a new Anthem Medicaid Reimbursement Policy based upon the Indiana Health Coverage Program s (IHCP) early elective delivery (EED) policy, effective July 1, See IHCP Bulletin BT for details. Additional details about Anthem s reimbursement policy can be found in Anthem s Medicaid Provider Operations Manual (POM). For access to the latest Manual, go online to > Indiana > Plan & Benefits > State Sponsored Plans > Hoosier Healthwise and Healthy Indiana Plan (HIP) > Provider Communications > Provider Manual and Important Updates. The IHCP and Indiana Anthem Blue Cross and Blue Shield Medicaid will not cover EEDs for dates of service on or after July 1, For deliveries performed prior to 39 weeks, 0 days will be covered only when certain approved medically necessary indications are present and documented. Please see below for billing instructions per this new policy. For professional claims on CMS-1500 forms: For deliveries with dates of service on or after July 1, 2014, one of the following modifiers will be required on the CMS-1500 claim form when billing with CPT codes 59409, 59514, and CPT delivery codes 59410, 59515, and are not covered. U9 Deliveries prior to 39 weeks, 0 days due to spontaneous labor. These claims will automatically pay. UB Medically necessary deliveries prior to 39 weeks, 0 days: Deliveries resulting from inductions or cesarean sections with a documented IHCP-approved medical indication (refer to IHCP Bulletin BT for approved indications). - Claims with the UB modifier and one of the diagnosis codes on the attached Anthem Medicaid Early Elective Delivery Medical Necessity Code List will pay. - If a claim is submitted with the UB modifier but without a code from the Anthem Medicaid Early Elective Delivery Medical Necessity Code List, medical records demonstrating medical necessity for delivery must be submitted with the claim. Submitted medical records will be reviewed prior to payment to determine if the delivery was medically necessary and the claim will pay or deny accordingly. In the case of denial, the provider retains the right to appeal. - If a claim is submitted with the UB modifier, but there is no diagnosis code on the claim from the Anthem Medicaid Early Elective Delivery Medical Necessity Code List and no records are submitted with the claim, the claim will deny. The provider will have the right to appeal and may submit medical records at that time. UC Deliveries at 39 weeks, 0 days of gestation or later, regardless of method (induction, cesarean section or spontaneous labor). These claims will automatically pay. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AINPEC May 2014

2 Page 2 of 8 UA Non-medically necessary deliveries prior to 39 weeks, 0 days of gestation: Deliveries prior to 39 weeks, 0 days of gestation that do not meet the IHCP s stated guidelines for approved medically necessary deliveries (please refer to IHCP Bulletin BT for approved conditions). These claims will automatically deny. The right to appeal is retained. For institutional claims on UB-04 forms: For deliveries with dates of admission on or after July 1, 2014, one of the following condition codes must be included on the UB-04 claim form, when applicable, and when billing with CPT codes 59409, 59514, and CPT delivery codes 59410, 59515, and are not covered. 81 Cesarean sections or inductions performed at less than 39 weeks, 0 days of gestation for medical necessity: - Claims with condition code 81 and one of the diagnosis codes on the attached Anthem Medicaid Early Elective Delivery Medical Necessity Code List will pay. - If a claim is submitted with the condition code 81, but without one of the codes from the Anthem Medicaid Early Elective Delivery Medical Necessity Code List, medical records demonstrating medical necessity for delivery must be submitted with the claim. Submitted medical records will be reviewed prior to payment to determine if the delivery was medically necessary and the claim will pay/deny accordingly. In the case of denial, the right to appeal is retained. - If a claim is submitted with the condition code 81, but there is no diagnosis code on the claim from the Anthem Medicaid Early Elective Delivery Medical Necessity Code List and no records are submitted with the claim, the claim will deny. The right to appeal is retained. Medical records may be submitted at the time of appeal request. 82 Cesarean sections or inductions performed at less than 39 weeks, 0 days of gestation: Use this condition code for deliveries prior to 39 weeks, 0 days of gestation that do not meet the IHCP s stated guidelines (please refer to IHCP Bulletin BT for approved conditions) for medically necessary deliveries. These claims will automatically deny. The right to appeal is retained. 83 Cesarean sections or inductions performed at 39 weeks, 0 days of gestation or later. These claims will automatically pay. An institutional claim for a delivery that was the result of spontaneous labor, regardless of route of delivery, should be submitted without a condition code. Institutional claims submitted without a condition code because the delivery was the result of spontaneous labor will automatically pay. All claims are subject to audit. For more information, please call Indiana Anthem Blue Cross and Blue Shield Customer Service at

3 Anthem Medicaid s Medical Necessity Code List DX Codes DX Description 042 Human Immunodeficiency Virus [HIV] 277.0x Cystic Fibrosis 282.xx Hereditary Hemolytic Anemias 283.xx Acquired Hemolytic Anemias 284.xx Aplastic Anemias Sideroblastic Anemia Coagulation Defects Qualitative Platelet Defects Immune Thrombocytopenic Purpura (ITP) Evans' syndrome Congenital and hereditary thrombocytopenic purpura Congenital neutropenia Functional disorders of polymorphonuclear neutrophils Genetic anomalies of leukocytes Eosinophilia Hemophagocytic syndromes Hypersplenism Chronic congestive splenomegaly Splenic sequestration Neutropenic splenomegaly Familial polycythemia Methemoglobinemia Primary hypercoagulable state 416.xx Chronic Pulmonary Heart Disease Thrombotic Thrombocytopenic Purpura (TTP) 491.xx Chronic Bronchitis 492.xx Emphysema 493.xx Asthma 494.xx Bronchiectasis 496.xx Chronic airway obstruction, not elsewhere classified Postinflammatory pulmonary fibrosis Idiopathic pulmonary fibrosis Regional enteritis of small intestine Regional enteritis of large intestine Regional enteritis of small intestine with large intestine Anthem Blue Cross and Blue Shield Page 3 of 8

4 Page 4 of Regional enteritis of unspecified site Unspecified ulcerative colitis Gastroenteritis and colitis due to radiation Toxic gastroenteritis and colitis Hemorrhage of gastrointestinal tract, unspecified Placenta previa without hemorrhage, unspecified as to episode of care Placenta previa without hemorrhage, with delivery Hemorrhage from placenta previa, unspecified as to episode of care Hemorrhage from placenta previa, with delivery Premature separation of placenta, unspecified as to episode of care Premature separation of placenta, with delivery Antepartum hemorrhage associated with coagulation defects, unspecified as to episode of care Antepartum hemorrhage associated with coagulation defects, with delivery Other antepartum hemorrhage, unspecified as to episode of care Other antepartum hemorrhage, with delivery Unspecified antepartum hemorrhage, unspecified as to episode of care Unspecified antepartum hemorrhage, with delivery Benign essential hypertension complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care Benign essential hypertension with delivery Benign essential hypertension, with delivery, with current postpartum Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care Hypertension secondary to renal disease, with delivery Hypertension secondary to renal disease, with delivery, with current postpartum Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care Other pre-existing hypertension, with delivery Other pre-existing hypertension, with delivery, with current postpartum Transient hypertension of pregnancy, unspecified as to episode of care Transient hypertension of pregnancy, with delivery Transient hypertension of pregnancy, with delivery, with current postpartum Mild or unspecified pre-eclampsia, with delivery, with current postpartum

5 Page 5 of Mild or unspecified pre-eclampsia, unspecified as to episode of care Mild or unspecified pre-eclampsia, with delivery Mild or unspecified pre-eclampsia, with delivery, with current postpartum Severe pre-eclampsia, unspecified as to episode of care Severe pre-eclampsia, with delivery Severe pre-eclampsia, with delivery, with current postpartum Eclampsia complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care Eclampsia, with delivery Eclampsia, with delivery, with current postpartum Pre-eclampsia or eclampsia superimposed on preexisting hypertension, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery, with current postpartum complicatio Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care Unspecified hypertension, with delivery Unspecified hypertension, with delivery, with current postpartum Unspecified renal disease in pregnancy, with delivery Unspecified renal disease in pregnancy, with delivery, with current postpartum Liver and biliary tract disorders in pregnancy, delivered, with or without mention of antepartum condition Maternal diabetes mellitus with delivery Maternal congenital cardiovascular disorders, with delivery Maternal congenital cardiovascular disorders, with delivery, with current postpartum Other maternal cardiovascular diseases, with delivery Other maternal cardiovascular diseases, with delivery, with current postpartum Abnormal glucose tolerance of mother, unspecified as to episode of care or not applicable Abnormal maternal glucose tolerance, with delivery

6 Anthem Blue Cross and Blue Shield Page 6 of 8 Abnormal maternal glucose tolerance, with delivery, with current postpartum Coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepar Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complic Epilepsy complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum Twin pregnancy, unspecified as to episode of care Twin pregnancy, delivered Triplet pregnancy, unspecified as to episode of care Triplet pregnancy, delivered Quadruplet pregnancy, unspecified as to episode of care Quadruplet pregnancy, delivered Twin pregnancy with fetal loss and retention of one fetus, unspecified as to episode of care or not applicable Twin pregnancy with fetal loss and retention of one fetus, delivered Triplet pregnancy with fetal loss and retention of one or more, unspecified as to episode of care or not applicable Triplet pregnancy with fetal loss and retention of one or more, delivered Quadruplet pregnancy with fetal loss and retention of one or more, unspecified as to episode of care or not applicable Quadruplet pregnancy with fetal loss and retention of one or more, delivered Other multiple pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not applicable Other multiple pregnancy with fetal loss and retention of one or more fetus(es), delivered Multiple gestation following (elective) fetal reduction, unspecified as to episode of care or not applicable Multiple gestation following (elective) fetal reduction, delivered, with or without mention of antepartum condition Other specified multiple gestation, unspecified as to episode of care Other specified multiple gestation, delivered

7 Page 7 of Unspecified multiple gestation, unspecified as to episode of care Unspecified multiple gestation, delivered Unstable lie of fetus, delivered Multiple gestation with malpresentation of one fetus or more, delivered Central nervous system malformation in fetus, with delivery Chromosomal abnormality in fetus, affecting management of mother, with delivery Suspected damage to fetus from viral disease in mother, affecting management of mother, with delivery Suspected damage to fetus from other disease in mother, affecting management of mother, with delivery Suspected damage to fetus from drugs, affecting management of mother, delivered Suspected damage to fetus from radiation, affecting management of mother, delivered Other known or suspected fetal abnormality, not elsewhere classified, affecting management of mother, delivery Fetal-maternal hemorrhage, unspecified as to episode of care or not applicable Fetal-maternal hemorrhage, with delivery Rhesus isoimmunization affecting management of mother, delivered Isoimmunization from other and unspecified blood-group incompatibility, affecting management of mother, delivered Fetal distress, affecting management of mother, unspecified as to episode of care or not applicable Fetal distress affecting management of mother, delivered Intrauterine death affecting management of mother, delivered Poor fetal growth, affecting management of mother, delivered Polyhydramnios, unspecified as to episode of care Polyhydramnios, with delivery Oligohydramnios, delivered Premature rupture of membranes, unspecified as to episode of care or not applicable Premature rupture of membranes in pregnancy, delivered Delayed delivery after spontaneous or unspecified rupture of membranes, delivered Infection of amniotic cavity, unspecified as to episode of care or not applicable Infection of amniotic cavity, delivered

8 Page 8 of 8 Abnormality in fetal heart rate or rhythm, delivered, with or without mention of antepartum condition Vasa previa complicating labor and delivery Vasa previa complicating labor and delivery, delivered Fetus or newborn affected by maternal death Chorioamnionitis V08 Asymptomatic Human Immunodeficiency Virus (HIV) infection status V23.5 Pregnancy with other poor reproductive history V27.1 Outcome of delivery, single stillborn