Medically Indicated Early-Term Deliveries (Prior to 39 Weeks) Coding Guidelines

POLICY NUMBER

None

DESCRIPTION

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POLICY

Induction of labor or cesarean section prior to 39 weeks gestation is not considered medically necessary unless certain criteria is met as indicated in the Medically Indicated Early-Term Deliveries (Prior to 39 Weeks) medical policy.

Effective January 1, 2015, all professional obstetric deliveries claims must include a modifier to identify the gestational age as of date of delivery. Any professional claim submitted without the use of an applicable modifier will require medical records to validate the gestational age and/or medically necessary maternal diagnosis for claim adjudication.

Effective April 1, 2015, any professional obstetric delivery claim submitted without the use of an applicable modifier will be rejected.

Effective October 1, 2015, ICD-10 diagnosis codes will be available to report the weeks of gestation and the policy will be updated as needed.

Indications and Filing Guidelines

The following modifiers will be required on the CMS-1500 claim form when filing with Current Procedural CPT maternity codes 59400, 59409-59410, 59414, 59510, 59514-59515, 59610, 59612, 59614, 59618, 59620, and/or 59622. On professional claims, the modifier is coded in the SV1 segment.

POLICY EXCEPTIONS

This policy is applicable to Local (Underwritten and Self-Funded groups), Blue Card, State of Mississippi, and FEP members with primary coverage.

POLICY GUIDELINES

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POLICY HISTORY

01/01/2015-Policy Enacted

SOURCE(S)

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CODE REFERENCE

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