Non-Global Maternity Care Policy Number: PG0003 ADVANTAGE | ELITE | HMO Last Review: 12/12/2017

INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO

GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

SCOPE X Professional _ Facility

DESCRIPTION Non-global maternity care is reported with each individual service on each date of service. Any visits to the physician/nurse midwife unrelated to global pregnancy can be submitted as a separate evaluation and management service (99201-99215). Each antepartum visit should have the modifier -TH appended to the service, along with the correct diagnosis as listed in the OB matrix. There is a separate and distinct procedure reported for every patient encounter performed: . Antepartum (Prenatal) care visits . Delivery care services . Postpartum care visits

There are four types of non-global delivery charges established by CPT:

1. Vaginal delivery (59409) 2. Cesarean delivery (59514) 3. Vaginal delivery after a previous Cesarean delivery (59612) 4. Cesarean delivery after failed vaginal delivery attempt after a previous Cesarean delivery (59620)

POLICY Non-Global Maternity Care does not require prior authorization.

COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage The OB provider is to report each individual service provided according to the OB matrix when they are reporting non-global maternity care.

Any submission of global services (59400, 59510, 59610, and 59618) will be denied. A provider is not allowed to mix global and non-global reporting.

ANTEPARTUM (PRENATAL) CARE HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage During the initial visit, the pregnancy is reported with an evaluation and management (E/M) service with the modifier –TH, and a corresponding obstetrical diagnosis. During this visit, it is expected that the E/M service reported will reflect the additional work involved in obtaining the complete medical history and examination required, as well as additional teaching services performed during the visit. All subsequent OB visits are “determined by the individual needs of the woman and the assessment of her risks,” according to the American College of Obstetricians and Gynecologists (ACOG). A routine OB E/M service should be reported as 99213 –TH,

PG0003 – 12/11/2020 based on ACOG and CPT criteria, and level of service expected. Antepartum visits are not defined as reportable services once labor has commenced, and are not defined as hospital visits prior to delivery. (Refer to PG0083 Obstetrical Treatment Services)

While CPT does not specify the number of expected antepartum visits, it is expected that at least 13 antepartum visits should occur and be reported. This expectation is based on ACOG, HEDIS, and state reporting guidelines. Only one provider will provide antepartum care, unless the care is transferred, or is referred to a specialist for consultation.

The routine antepartum visits include an educational plan with the following topics discussed; anesthesia, breast or bottle feeding, selection of a physician for the newborn, car seat and safety, tubal sterilization, circumcision, limitations, and restrictions. While this list is not all inclusive, it is an indicator of expected teaching performed during a routine pregnancy. This educational plan also includes discussions related to routine laboratory and radiological testing. This testing can include CBC, diabetes screening, glucose tolerance testing (if screening was abnormal), Rh antibody screening, Rhogam at 28 weeks (if indicated), as well as Syphilis IgG, GC, chlamydia screening, Group B strep screening, and ultrasounds. The laboratory and radiological testing are services reported separately, but the review of these services by the OB/GYN provider is considered a component of the routine obstetrical plan of care.

The documentation for supporting antepartum services are supported by ACOG, and their development of an antepartum flow sheet used to report the standard 13 antepartum visits (monthly visits up to 28 weeks, biweekly visits up to 36 weeks and then weekly visits to delivery). The subsequent visits include blood pressure, weight, urine for sugar and albumin, fundal height, and fetal heart tones beginning at 10-12 weeks by Doppler.

Advantage For Advantage members only, there are additional prenatal services that may be considered for reimbursement (H1000-H1003) that have separate policy reimbursement guidelines, unrelated to the global or non-global maternity reimbursement. These services have separate and distinct documentation requirements unrelated to the defined routine obstetrical care, and can only be reported when these additional specific documentation guidelines have been met. (Refer to PG0002 Supplemental Obstetrical Prenatal Care Services)

DELIVERY HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Labor and delivery services are based on the need of each individual patient and can include, but not limited to, the following types of services; fetal monitoring of any type, rupture of membranes, amnioinfusion, forceps and/or vacuum assisted delivery, episiotomy and/or laceration repair, as well as fetal and maternal testing, and induction of labor services.

The delivery fees reflect all hospital services, and inpatient E/M services performed. Pre- and post-delivery services are considered inclusive to the delivery. Delivery services are defined as beginning when labor has commenced or upon admission to the hospital, whichever comes first. Antepartum and postpartum care directly related to the delivery are included within the scope of the delivery.

Advantage

Caesarean section, labor induction, or any delivery following labor induction is subject to the following criteria:

 Gestational age of the fetus must be determined to be at least thirty-nine weeks or  If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery.

NOTE: Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to thirty-nine weeks gestation that are not considered medically necessary are not eligible for payment.

PG0003 – 12/11/2020 Paramount requires that all claims for a delivery procedure (mother’s claim, not child’s claim) must include the weeks of gestation ICD-10 diagnosis code (as listed below).

MULTIPLE BIRTHS HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan Paramount has adopted the billing guidelines for Multiple Birth reporting as set forth by The American College of Obstetricians and Gynecologists (ACOG).

Vaginal Delivery Reporting

 Primary delivery service code: 59409 or 59612  No additional procedural delivery code warranted.  Modifier 51 should be added to support substantial additional work.  Each additional delivery code: 59409-51 or 59612-51  If the additional service becomes a C-section, then report the primary delivery service as a C-section delivery: 59514 or 59620

Cesarean Delivery Reporting  Primary delivery service code: 59514 or 59620  No additional procedural delivery code warranted.  Modifier 22 should be added to support substantial additional work.  Only a single C-section delivery service is to be reported no matter how many live births: 59514-22, 59620- 22

Advantage Payment Determined in the Following Manner:  For a single delivery or the first delivery of a multiple birth, it is one hundred percent  For the second delivery of a multiple birth, it is fifty percent  For the third delivery of a multiple birth, it is twenty-five percent  No payment is made for additional deliveries

Vaginal and Cesaren Delivery Reporting  Primary delivery service code: 59409, 59612, 59514, 59620  No additional procedural delivery code warranted.  Modifier 51 should be added to support substantial additional work.  Each additional delivery code: 59409-51, 59612-51, 59514-51, 59620-51  If the additional service becomes a C-section, then report the primary delivery service as a C-section delivery: 59514 or 59620

POSTPARTUM CARE HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Postpartum care is defined as office visits following any type of delivery, and does not include inpatient hospital care immediately following delivery. Only a single provider provides postpartum care. The member will have postpartum care related to their medical needs with the final visit at the conclusion of the postpartum period. Each of these visits can be reported with the appropriate level of E/M service supporting the level of care provided within the documentation, and following CPT documentation guidelines.

Postpartum care office visits following vaginal or C-section delivery can include any number of visits, but usually extend over a six-week period. The final postpartum visit is to be reported with procedure code 59430 [Postpartum care only (separate procedure)]. This is reimbursed as a single postpartum examination and is reimbursed at the same rate as procedure code 99215 within the respective provider fee schedule (e.g. Metro-Standard, Metro- Preferred). This service is used for reporting purposes in order to follow ACOG, HEDIS, and state reporting guidelines.

PG0003 – 12/11/2020 Procedure code 59430 should only be billed by a provider that did not provide any antepartum or delivery services/procedures for the patient. The provider only provided postpartum care to the patient/member. If the provider performed the delivery then they should be billing for the postpartum services/procedures with the appropriate non-global coding (99201-99215).

If an unrelated procedure is performed during an postpartum visit, modifier -25 will be appended to the E/M service to indicate that separate and distinct services were performed.

CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. CPT CODES 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59430 Postpartum care only (separate procedure) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery 99201 Office or other outpatient visit for the evaluation and management of a new patient; history, exam, straightforward decision-making; 10 minutes 99202 Office or other outpatient visit for the evaluation and management of a new patient; expanded history, exam, straightforward decision-making; 20 minutes 99203 Office or other outpatient visit for the evaluation and management of a new patient; detailed history, exam, straightforward decision-making; 30 minutes 99204 Office or other outpatient visit for the evaluation and management of a new patient; comprehensive history, exam, moderate complexity decision-making; 45 minutes 99205 Office or other outpatient visit for the evaluation and management of a new patient; comprehensive history, exam, high complexity decision-making; 60 minutes 99211 Office or other outpatient visit for the evaluation and management of an established patient; evaluation and management, may not require presence of physician; 5 minutes 99212 Office or other outpatient visit for the evaluation and management of an established patient; history, exam, straightforward decision-making; 10 minutes 99213 Office or other outpatient visit for the evaluation and management of an established patient; expanded history, exam, straightforward decision-making; 15 minutes 99214 Office or other outpatient visit for the evaluation and management of an established patient; office visit (25 minutes face to face) 99215 Office or other outpatient visit for the evaluation and management of an established patient; office visit (25 minutes face to face) MODIFIERS 22 Increased Procedural Service requiring work substantially greater than typically required 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure 51 Multiple surgeries performed on the same day, during the same surgical session TH Obstetrical treatment/services, prenatal or postpartum ICD-10 REQUIRED FOR ALL CLAIMS FOR A DELIVERY PROCEDURE FOR ADVANTAGE Codes Z3A.00 Gestation not specified Z3A.01 Less than 8 weeks Gestation of Pregnancy Z3A.08 8 weeks gestation of pregnancy Z3A.09 9 weeks gestation of pregnancy Z3A.10 10 weeks gestation of pregnancy Z3A.11 11 weeks gestation of pregnancy Z3A.12 12 weeks gestation of pregnancy

PG0003 – 12/11/2020 Z3A.13 13 weeks gestation of pregnancy Z3A.14 14 weeks gestation of pregnancy Z3A.15 15 weeks gestation of pregnancy Z3A.16 16 weeks gestation of pregnancy Z3A.17 17 weeks gestation of pregnancy Z3A.18 18 weeks gestation of pregnancy Z3A.19 19 weeks gestation of pregnancy Z3A.20 20 weeks gestation of pregnancy Z3A.21 21 weeks gestation of pregnancy Z3A.22 22 Weeks gestation of pregnancy Z3A.23 23 Weeks gestation of pregnancy Z3A.24 24 Weeks gestation of pregnancy Z3A.25 25 Weeks gestation of pregnancy Z3A.26 26 Weeks gestation of pregnancy Z3A.27 27 Weeks gestation of pregnancy Z3A.28 28 Weeks gestation of pregnancy Z3A.29 29 Weeks gestation of pregnancy Z3A.30 30 Weeks gestation of pregnancy Z3A.31 31 Weeks gestation of pregnancy Z3A.32 32 Weeks gestation of pregnancy Z3A.33 33 Weeks gestation of pregnancy Z3A.34 34 Weeks gestation of pregnancy Z3A.35 35 Weeks gestation of pregnancy Z3A.36 36 Weeks gestation of pregnancy Z3A.37 37 Weeks gestation of pregnancy Z3A.38 38 Weeks gestation of pregnancy Z3A.39 39 Weeks gestation of pregnancy Z3A.40 40 Weeks gestation of pregnancy Z3A.41 41 Weeks gestation of pregnancy Z3A.42 42 Weeks gestation of pregnancy Z3A.49 Greater than 42 weeks Gestation of Pregnancy

REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 10/30/2005 11/01/06: No change 12/01/07: No change 10/01/08: Multi-gestational deliveries 03/01/10: Updated 04/12/12: No changes 09/09/14: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 11/08/16: For Advantage modifier 51 should be used to report multiple birth vaginal or cesarean deliveries. Modifier 22 is no longer correct per ODM guidelines. Added payment determination for multiple birth deliveries per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 12/12/17: Added ICD-10 diagnosis codes Z3A.00-Z3A.49 required for all claims for a delivery procedure for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 12/11/2020: Medical policy placed on the new Paramount Medical Policy Format

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

PG0003 – 12/11/2020 Industry Standard Review Hayes, Inc.

PG0003 – 12/11/2020