Tuesday, May 10, 2016

CPT CODE 59510, 59514, 59425, 59426, 59410 And S5100 with modifier usage

CPT Code Description

59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

59412 External cephalic version, with or without tocolysis

59414 Delivery of placenta (separate procedure)

59425 Antepartum care only; 4-6 visits

59426 Antepartum care only; 7 or more visits

59430 Postpartum care only (separate procedure)

59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care

59514 Cesarean delivery only

59515 Cesarean delivery only; including postpartum care

59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure)

59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)

59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care

59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery

59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery

59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care

Antepartum Care Only

The CPT Editorial Board created codes 59425 (Antepartum care only; 4-6 visits) and 59426 (Antepartum care only; 7 or more visits) to accommodate for situations such as termination of a pregnancy, relocation of a patient or change to another physician. In these situations, all the routine antepartum care (usually 13 visits) or global (OB) care may not be provided by Same Group Physician and/or Other Health Care Professional.

The Antepartum Care Only CPT codes 59425 or 59426 should be reported by Same Group Physician and/or Other Health Care Professionals when:

** The antepartum care provided does not meet the routine antepartum care definition of the global OB package as defined by CPT; or

** The antepartum care provided is less than the typical number of visits (usually 13) during the global OB package as defined by ACOG.

If the patient is treated for antepartum services only, the physician and/or other health care professional should use CPT code 59426 if 7 or more visits are provided, CPT code 59425 if 4-6 visits are provided, or itemize each E/M visit if only providing 1-3 visits. As described by ACOG and the AMA, the Antepartum Care Only codes 59425 and 59426 should be reported as described below:

** A single claim submission of CPT code 59425 or 59426 for the antepartum care only, excluding the confirmatory visit that may be reported and separately reimbursed when the antepartum record has not been initiated.

** The units reported should be one (1).

** The dates reported should be the range of time covered. For example, if the patient had a total of 4-6 antepartum visits then the physician and/or other health care professional should report CPT code 59425 with the "from and to" dates for which the services occurred.


** Exception: MS CAN providers are to submit antepartum codes 59425/59426 per date of service.

When date ranges span across the effective date of ICD-9-CM to ICD-10-CM for antepartum services see Q&A #1.

In the event that all the antepartum care was provided, but only a portion of the antepartum care was covered under UnitedHealthcare Community Plan, then adjust the number of visits reported and the "from and to" dates to reflect when the patient became eligible under UnitedHealthcare Community Plan coverage.

State Exceptions

Arizona Routine prenatal visits are not reimbursed with a global code but providers must submit the appropriate antepartum visit code, either 59425 or 59426, in order to be reimbursed for the global code. In other words, the antepartum code must be reported but will not be reimbursed.

Delaware Global OB codes will not be reimbursed, providers must unbundle the components and bill them separately. Delivery plus postpartum codes may be used.

Maryland Global OB codes will not be reimbursed, providers must unbundle the components and bill them separately. Delivery plus postpartum codes may be used.

Antepartum codes 59425 & 59426 will not be reimbursed; providers must submit E&M codes.Mississippi CAN

Global OB codes will not be reimbursed, providers must unbundle the components and bill them separately. Delivery plus postpartum codes may be used. Multiple gestations delivered by C-Section: multiple deliveries are reimbursable, one delivery + postpartum (or delivery only if appropriate) and additional delivery only for additional babies.

Antepartum visits are to be itemized, as follows:

o Providers must bill CPT Codes in the 99201 through 99215 range for antepartum visits 1 or 2 or 3. Bill one code per visit.

o Providers must bill CPT code 59425 for antepartum visits 4, 5, or 6. Bill one code per visit.

o Providers must bill CPT code 59426 for antepartum visits 7 or over. Bill one code per visit.

Ohio Global OB codes will not be reimbursed, providers must unbundle the components and bill them separately. Delivery plus postpartum codes may be used. Antepartum codes 59425 & 59426 will not be reimbursed; providers must submit E&M codes.

Claims for delivery will not be reimbursed unless delivery diagnosis codes that have the week of gestation in their description are used (Code list in Attachments). Pennsylvania Antepartum visits are to be itemized. PA providers are to submit appropriate level E&M codes in addition to the global or most comprehensive code; MS are to submit antepartum codes 59425/59426 per date of service.Texas Global OB codes will not be reimbursed, providers must unbundle the components and bill them separately.

Delivery plus postpartum codes may be used. Antepartum codes 59425 & 59426 will not be reimbursed; providers must submit E&M codes.

Q: If a physician provides antepartum services when the “from” and “to” dates span across ICD-9- CM to ICD-10-CM code sets, and global maternity service codes are used, such as CPT 59425 or 59426, how should the services be reported ?

A: To facilitate correct payment and application of benefits in the UnitedHealthcare claims system, when the date span crosses ICD-9-CM to ICD-10-CM code sets, the “from date” of service should be reported with the correct ICD code from the applicable code set for that date of service. Example: Report the diagnosis using the ICD code set that is in effect for the date of service in the “from date” field. If the date in the “from date” field is on or before Sept. 30, 2015, use the ICD-9- CM code. If the date in the “from date” field is on or after Oct. 1, 2015, use the ICD-10-CM code.

Note: Global maternity care codes for services that span over the ICD-10 effective date do not need to be split on two lines to accommodate the implementation of ICD-10-CM. If an OB global code and/or antepartum services procedure code is reported on two or more claims by the Same Group Physician and/or Other Health Care Professional, only the first unit processed will be considered, all subsequent units will be rejected and not separately reimbursed

Q: What does the phrase “changes insurers” mean in relation to itemization of Obstetric (OB) Related E/M Services?

A: For the purposes of this policy, “insurer” means a third party payer. If a patient changed insurers  during her OB care, the physician and/or other health care professional would separate and submit the OB services that were provided in an itemized format to each insurer. For example, when reporting the antepartum care services, the code selection depends on how many visits were performed while covered under each insurer. The physician and/or other health care professional should report CPT code 59426 when 7 or more visits are provided, CPT code 59425 when 4-6 visits are provided, or an E/M visit when only providing 1-3 visits.

For purposes of this policy, “change insurers” could also mean that a patient continues to be covered under one insurer, but changes coverage for that insurer. The physician and/or other health care profession

59426 Antepartum care only; 7 or more visits

59430 Postpartum care only (separate procedure)

59510 Routine obstetric care including antepartum care, cesarean delivery, andpostpartum care

59514 Cesarean delivery only;

59515 Cesarean delivery only; including postpartum care

59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps);

59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care

59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery

59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;


59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care


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Incomplete Antepartum Care Service CPT

Billing for Incomplete Antepartum Care

59425 When billing for four to six prenatal visits
59426 When billing for seven or more prenatal visits with or without an initial visit


Postpartum Care 

Service CPT Modifier

Billing for Multiple Deliveries  For additional babies:    59409, 59514, 59612, or 59620  51 and 59


Oral and Maxillofacial 

Surgery Service HCPCS

Oral and Maxillofacial Surgery
Do not use CPT procedure code 41899, as this is an unspecified code and will cause delay in payment for services.


Physician Service Policy Service Modifier

Locum Tenens and Reciprocal Billing
Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement.
Q6 - Service furnished by a locum tenens physician


Adult Day Care (Health) HCPCS Description Modifier Place of Service


S5100 Day Care Services, Adult
1 Unit = 15 minutes
U2 modifier is no longer required when billing this service code.
12 Home 99 Other (Community)


Global prenatal care includes all prenatal visits performed at medically appropriate intervals up to the date of delivery, routine urinalysis testing during the prenatal period, care for pregnancy related conditions (e.g. nausea, vomiting, cystitis, vaginitis), and the completion of the Risk Appraisal for Pregnant Women form. Only one prenatal care code, 59425 (four-six visits) or 59426 (seven or more visits), may be billed per pregnancy. The date of the delivery is the date of service to be used when billing the global prenatal codes. If a provider does more than three visits but the participant goes to another provider for the rest of her pregnancy, all visits must be billed using the appropriate office visit procedure codes.

Billing for global services cannot be done until the date of delivery.

OTHER BILLING REQUIREMENTS

• All claims with global and delivery procedure codes must show the date of the last menstrual period (LMP) in Field 14 on the CMS-1500 claim form.

• If billing a global delivery code or other delivery code, use a delivery diagnosis on the claim, e.g., 650, 669.70, etc.

• If billing a global prenatal code, 59425 or 59426, or other prenatal services, a pregnancy diagnosis, e.g., V22.0, V22.1, etc. is required on the claim.



Maternity Service Number of Visits Coding

Antepartum Care Only 1 to 3 visits Use the appropriate Evaluation & Management (E/M) codes

Antepartum Care Only 4 to 6 visits Use CPT code 59425 and one (1) unit

Antepartum Care Only 7 or more visits Use CPT code 59426 and one (1) unit Postpartum Care Only Use CPT 59430

Coding

The current CPT publication defines the following maternity-related services as:

+ 59400 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

+ 59409 - Vaginal delivery only (with or without episiotomy and/or forceps)

+ 59410 - Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

+ 59425 - Antepartum care only; 4-6 visits

+ 59426 - Antepartum care only; 7 or more visits

+ 59430 - Postpartum care only (separate procedure)

+ 59510 - Routine obstetric care including antepartum care, cesarean delivery, and postpartum care

+ 59514 - Cesarean delivery only

+ 59515 - Cesarean delivery only; including postpartum care

+ 59610 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean  delivery

+ 59612 -Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)

+ 59614 - Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care

+ 59618 - Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean  delivery

+ 59620 - Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery

+ 59622 - Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care

Note: Physicians should reference the CPT publication for the most current and any additional maternity-related service codes. Should any of the above codes change, the most current code should be submitted on the claim form. BCBSNC system edits are in place to apply correct coding guidelines for CPT, HCPCS, and current ICD diagnosis and procedure codes. BCBSNC system edits enforce and assist in a consistent claim review process. BCBSNC coding edits reflect medical coverage guidelines, benefit plans, and/or other BCBSNC policies. Unbundling, mutually exclusive procedures, duplicate, obsolete, or invalid codes are identified through the use of coding edits.



MATERNITY SERVICES bcbs guidelines

BCBSTX requires itemization of maternity services when submitting claims for reimbursement. Please use the appropriate CPT or HCPCS codes and ICD diagnosis codes when billing. This includes the applicable “Evaluation and Management” code, along with coding for all other procedures performed. Delivery charges should be billed with  appropriate CPT codes.

Code Description

59409 Vaginal Delivery Only
59410 Vaginal Delivery Only (with or without episiotomy and/or forceps), inducing postpartum care
59515 Cesarean Section Only (including postpartum care)
59614 Vaginal Delivery Only, After Previous Cesarean Delivery (with or without episiotomy and/or forceps) (including postpartum care)
59622 Cesarean Section Only, Following Attempted Vaginal Delivery After Previous Cesarean Delivery (including postpartum care)

Claims for Obstetric Deliveries to Require a Modifier

Claims submitted for obstetric deliveries with procedure codes 59409, 59410, 59514, 59515, 59612, 59614, 59620, or 59622 will require one of the following modifiers:


Modifier Description

U1 Medically necessary delivery prior to 39 weeks of gestation

U2 Delivery at 39 weeks of gestation or later

U3 Non-medically necessary delivery prior to 39 weeks of gestation

Note:  Claims for deliveries that are submitted without one of the required modifiers will be denied. BCBSTX restricts any Cesarean section, labor induction, or any delivery following labor induction to one of the following additional criteria:

Gestational age of the fetus should be determined to be at least 39 weeks or fetal lung maturity must be established before delivery.

When the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery.

Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to 39 weeks of gestation and are not considered medically necessary will be denied.

Records will be subject to retrospective review. Payments made for non-medically indicated Cesarean section, labor induction, or any delivery following labor induction that fail to meet these criteria (as determined by review of medical documentation), will be subject to recoupment. Recoupment may apply to all services related to the delivery, including additional physician fees and the hospital fees.

For more information, call the TMHP Contact Center at 800-925-9126.


BCBSTX reimburses only one delivery or cesarean section procedure per Member in a seven- month period. Reimbursement includes multiple births.

Delivering physicians who perform regional anesthesia or nerve block may not receive additional reimbursement because these charges are included in the reimbursement for the delivery.

BCBSTX reimburses anesthesia services and delivery at full allowance when provided by the delivering obstetrician.

BCBSTX will reimburse antepartum care, deliveries, including cesarean sections performed by physicians, and postpartum care. (Codes 59410, 59515, 59614 and 59622 are deliveries that include the postpartum visit.)

When billing BCBSTX, you must itemize each service individually and submit claims as the services are rendered. The filing deadline will be applied to each individual date of service submitted to BCBSTX.

Laboratory (including pregnancy test) and radiology services provided during pregnancy must be billed separately and be received by BCBSTX within 95 days from the date of service.

Use modifier TH, obstetrical treatment or service, prenatal or postpartum, with all antepartum procedure codes.

Initial prenatal visits are payable with the following CPT codes along with modifier TH:

99201 = Office/Outpatient Visit, New – Minor
99202 = Office/Outpatient Visit, New – Low to Moderate Severity
99203 = Office/Outpatient Visit, New – Moderate Severity
99204 = Office/Outpatient Visit, New – Moderate Complexity; Moderate to High Severity
99205 = Office/Outpatient Visit, New – High Complexity, Moderate to High Severity An ‘initial prenatal visit’ is defined as the first pregnancy-related office visit. Providers must bill the most appropriate new or established patient prenatal or postpartum visit procedure code. New patient codes may be used when the client has not received any professional services from the same physician or a physician of the same specialty who belongs to the same group, within the past three years Postpartum care visits are payable with the following CPT codes along with modifier TH:
99211 = Office/Outpatient Visit, Established – Minor
99212 = Office/Outpatient Visit, Established – Low to Moderate Severity
99213 = Office/Outpatient Visit, Established – Moderate Severity
99214 = Office/Outpatient Visit, Established – Moderate Complexity, Moderate to High Severity
99215 = Office/Outpatient Visit, Established – High Complexity, Moderate to High Severit     Postpartum care provided after discharge must be billed with CPT code 59430 and modifier TH.

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