Medically Indicated Early-Term Deliveries (Prior to 39 Weeks) Coding Guidelines (Dates of Service on or after 10/1/2015)

POLICY NUMBER

None

DESCRIPTION

None

POLICY

Effective for dates of service on or after October 1, 2015

Blue Cross and Blue Shield of Mississippi (BCBSMS) will no longer require all professional obstetric deliveries claims to include a modifier to identify the gestational age as of date of delivery. ICD-10 diagnosis codes will be available to report the weeks of gestation. The weeks of gestation and delivery outcome are required to be reported on both professional and facility delivery claims. The facility is required to report the weeks of gestation and the delivery outcome only.

Effective for dates of service on or after January 1, 2016

Providers will also be required to report the type of labor, delivery method and the number of deliveries associated with the delivery method on the professional delivery claim.

Indications and Filing Guidelines

To report the weeks of gestation and the delivery outcome, the appropriate ICD-10 diagnosis codes should be used from the following categories: Z3A (weeks of gestation) and Z37 (delivery outcome) and reported in block 21 (A-L) on the HCFA-1500 and blocks 68 and 69 on the UB-04 claim forms as appropriate.

Please note: This portion of the coding policy will become effective on January 1, 2016.

The type of labor, type of delivery method and number of deliveries for the type of delivery method is summarized into one delivery indicator. The type of delivery methods include: vaginal delivery, C-section delivery, and vaginal birth after C-section. The types of labor include spontaneous, induced, or no labor. The number of deliveries for the type of delivery method includes a number field (#), which may include double digits.

For electronic professional delivery claims, providers will include the delivery indicator in the notes field at the line level (loop 2400).

Please note that the number of deliveries is specific to the type of delivery method. See examples below.

• Patient A has 3 pregnancies:

  • Patient A is expecting her first child. She is 40 weeks gestation (Z3A.40) and enters the hospital in spontaneous labor, which results in a vaginal delivery. The professional delivery claim submitted for Patient A would have a delivery indicator of SLV1.

  • Patient A is expecting her second child. She is 39 weeks gestation (Z3A.39) and enters the hospital for an induction as a result of pregnancy induced hypertension, which results in a C-section delivery. The professional delivery claim submitted for Patient A would have a delivery indicator of ILC1.

  • Patient A is expecting her third child. She is 39 weeks gestation (Z3A.39) and enters the hospital for an induction, which results in a vaginal birth after C-section. The professional delivery claim submitted for Patient A would have a delivery indicator of ILB1.

Any professional and/or facility delivery claim submitted without the use of ICD-10 codes indicating the delivery outcome, gestation week, and/or applicable type of delivery and labor value will be rejected. Medical records may also be requested to validate the gestational age, delivery outcome, type of delivery, type of labor, and/or medically necessary maternal diagnosis for claim adjudication.

POLICY EXCEPTIONS

None.

POLICY GUIDELINES

Professional and facility delivery claims must have the clinical delivery information as outlined above for adjudication. As of October 1, 2015, in the event that the professional and facility delivery claims do not have the above required information, the claim will be rejected and/or require a medical record request and review to validate the gestational age and/or the medically necessary maternal diagnosis.

Professional and facility medical records documentation must indicate the weeks of gestation, type of delivery, and type of labor with the number of deliveries for the specific delivery method and any medical diagnosis indications for early elective delivery. BCBSMS will also be verifying and matching facility and professional claims for claim adjudication. Facility claims will be matched to the professional claims for gestational age verification. Therefore, professional and facility claims should be submitted timely.

Professional and facility delivery claims for elective deliveries that occur before 39 weeks gestation will be denied as not medically necessary per the Medically Indicated Early-Term Deliveries (Prior to 39 Weeks) with a member held harmless. If a global delivery code is submitted, professional providers will be required to submit antepartum and postpartum codes separately from the delivery code if the elective delivery is before 39 weeks gestation without medical necessity documentation.

The coding guidelines outlined in this Coding Policy should not be used in lieu of the Member's specific benefits plan language.

POLICY HISTORY

01/01/2015-Policy Enacted

09/1/2015-Policy Revised

SOURCE(S)

None

CODE REFERENCE

None