Notification



Notification Issue Date:



Claim Payment Policy


Title:Billing Requirements for Multiple Births for Professional Providers

Policy #:00.10.38

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

The Company has established billing requirements for multiple births, which includes reporting the appropriate primary diagnosis code, procedure code, and, as applicable, the modifier-procedure code-combinations that best describe the delivery scenario.

All multiple births must be reported using the following:
  • An American Medical Association (AMA) Current Procedural Terminology (CPT) code that corresponds to the type of delivery and, as appropriate:
    • A procedure code modifier (modifier 22 or 59), in the first modifier position on the claim form
  • A primary International Classification of Diseases, 9th Revision Clinical Modification (ICD-9 CM) code
    Refer to Attachments A, B, C, and D for examples of multiple birth coding scenarios.


BILLING REQUIREMENTS FOR MULTIPLE BIRTHS

CESAREAN DELIVERY
  • Routine Obstetric Care Provided
    Report:
    • The CPT code that represents the routine care of individuals who deliver by cesarean delivery and corresponds to the type of cesarean:
      • For cesarean delivery, report 59510, with modifier 22 as a single line item
      • For cesarean delivery following attempted VBAC, report 59618, with modifier 22 as a single line item
  • Delivery Only
    Report:
    • The CPT code that represents only the cesarean delivery and corresponds to the type of cesarean:
      • For cesarean delivery, report 59514, with modifier 22 as a single line item
      • For cesarean delivery following attempted VBAC, report 59620, with modifier 22 as a single line item
  • Delivery and Postpartum Care Provided
    Report:
    • The CPT code that represents only the cesarean delivery with postpartum care and corresponds to the type of cesarean delivery:
      • For cesarean delivery, report 59515, with modifier 22 as a single line item
      • For cesarean delivery following attempted VBAC, report 59622, with modifier 22 as a single line item

VAGINAL DELIVERY
  • Routine Obstetric Care Provided
    Report:
    • For Baby A, report the CPT code that represents the routine obstetric care of individuals who deliver by vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59400.
      • For VBAC, report 59610.
    • For Baby B, Baby C, etc., report the CPT code that represents only the vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59409, with modifier 59 as a separate line item for each neonate delivered
      • For VBAC, report 59612, with modifier 59 as a separate line item for each neonate delivered
  • Delivery Only
    Report:
    • For Baby A, report the CPT code that represents only a vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59409.
      • For VBAC, report 59612.
    • For Baby B, Baby C, etc., report the CPT code that represents only the vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59409, with modifier 59 as a separate line item for each neonate delivered.
      • For VBAC, report 59612, with modifier 59 as a separate line item for each neonate delivered.
  • Delivery and Postpartum Care Provided
    Report:
    • For Baby A, report the CPT code that represents only a vaginal delivery with postpartum care and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59410.
      • For VBAC delivery, report 59614.
    • For Baby B, Baby C, etc., report the CPT code that represents only a vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59409, with modifier 59 as a separate line item for each neonate delivered.
      • For VBAC, report 59612, with modifier 59 as a separate line item for each neonate delivered.

COMBINATION OF VAGINAL AND CESAREAN DELIVERIES
  • Routine Obstetric Care Provided
    Report:
    • For each cesarean-delivered neonate(s), report the CPT code that represents the routine care of individuals who deliver by cesarean delivery and corresponds to the type of cesarean delivery as a single line item:
      • For cesarean delivery of one neonate, report 59510.
      • For cesarean delivery of one neonate following attempted VBAC, report 59618.
      • For cesarean delivery of more than one neonate, report the appropriate CPT code listed above to represent the type of cesarean delivery, with modifier 22 on one claim line (ie, 59510-22 or 59618-22).
    • For each vaginally-delivered neonate(s), report the CPT code that represents only the vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59409, with modifier 59 as a separate line item for each neonate delivered.
      • For VBAC, report 59612, with modifier 59 as a separate line item for each neonate delivered.
  • Delivery Only
    Report:
    • For each cesarean-delivered neonate(s), report the CPT code that represents only the cesarean delivery and corresponds to the type of cesarean delivery, as a single line item:
      • For cesarean delivery of one neonate, report 59514.
      • For cesarean delivery of one neonate, following attempted VBAC, report 59620.
      • For cesarean delivery of more than one neonate, report the appropriate CPT code listed above to represent the type of cesarean delivery, with modifier 22 as a single line item (ie, 59514-22 or 59620-22).
    • For each vaginally-delivered neonate(s), report the CPT code that represents only the vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59409, with modifier 59 as a separate line item for each neonate delivered.
      • For VBAC delivery, report 59612, with modifier 59 as a separate line item for each neonate delivered.
  • Delivery and Postpartum Care Provided
    Report:
    • For each cesarean delivered neonate(s), report the CPT code that represents only the cesarean delivery with postpartum care and corresponds to the type of cesarean delivery, as a single line item:
      • For cesarean delivery of one neonate, report 59515.
      • For cesarean delivery of one neonate, following attempted VBAC, report 59622.
      • For cesarean delivery of more than one neonate, report the appropriate CPT code with Modifier 22: 59515-22 or 59622-22
    • For each vaginally-delivered neonate(s), report the CPT code that represents only the vaginal delivery and corresponds to the type of vaginal delivery:
      • For vaginal delivery, report 59409 with modifier 59, as a separate line item for each neonate delivered.
      • For VBAC delivery, report 59612-59 with modifier 59, as a separate line item for each neonate delivered.
Note: The CPT code for the cesarean delivery and/or each vaginal delivery is reported on one claim line as one unit, regardless of the number of neonates delivered.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, multiple births are covered under the medical benefits of the Company's products.

MEDICARE

There is no Medicare coverage determination addressing this service; therefore, the Company policy is applicable. The Company's payment methodology may differ from Medicare.

BILLING GUIDELINES

Multiple surgery reduction guidelines are applied to procedure codes reported for multiple births.

Additional reimbursement may be considered on a post-payment basis for cesarean delivery of triplets or more.
Description

A multiple birth is the delivery of two or more neonates (ie, twins, triplets, or other high-order multiples [quadruplets, etc.]) that have been carried by the same mother during the same pregnancy.
Generally, the delivery of a neonate is reported using a procedure code that represents routine obstetric care. However, if more than one neonate is delivered, in some delivery scenarios, additional procedure codes may be required to represent the subsequent delivery of additional neonates.
Routine obstetric care includes the following components:
  • Antepartum care includes, when provided in its entirety, monthly visits up to 28 weeks’ gestation; biweekly visits to 36 weeks’ gestation; and weekly visits until delivery, which is a total of approximately 13 antepartum visits.
  • Delivery services include the admission to the hospital for the delivery; admission history and physical examination; management of uncomplicated labor; and vaginal delivery (with or without episiotomy, with or without forceps) or cesarean (C-section) delivery.
  • Postpartum care includes hospital and office visits following vaginal or cesarean (C-section) delivery.

As used in this policy:
  • Professional health care provider refers to the professional provider who performs the health care service, as well as to any professional provider in the same provider group practice.
  • Neonate refers to the newborn (newborn baby) at the time of delivery.
  • Baby A refers to the first neonate delivered. Baby B, C, etc. refers to subsequently delivered neonates.
    References

    Beebe M. Principles of CPT®. 5th ed. Chicago, IL: American Medical Association; 2008.

    Company benefit contracts

    Holden K, Orme N, eds. 2009 Ingenix Learning: Understanding Modifiers.West Valley City, UT: Ingenix, Inc.; 2008.

    The American College of Obstetricians and Gynecologists (ACOG). [ACOG Website]. Available at: http://www.acog.org/ Accessed on 9/14/2010.



    Coding

    Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

    The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

    In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

    The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

REPORT THE PROCEDURE CODE(S) THAT APPLY TO THE SPECIFIC MULTIPLE BIRTH SCENARIO WITH THE APPROPRIATE MODIFIER(S) AS IDENTIFIED IN THIS POLICY:

59400, 59409, 59410, 59510, 59514, 59515, 59610,
59612, 59614, 59618, 59620, 59622

REFER TO THE FOLLOWING POLICY ATTACHMENTS FOR EXAMPLES OF CODING SCENARIOS FOR MULTIPLE BIRTHS:
  • Attachment A: Examples of Coding Scenarios for Reporting Twin Births when Routine Obstetric (Global Maternity/Obstetric [OB]) Care was Provided
  • Attachment B: Examples of Coding scenarios for Reporting Twin Births when Antepartum Care was not Provided
  • Attachment C: Examples of Coding Scenarios for Reporting High-Order Multiple (Triplets, Quadruplets, etc.) Births when Routine Obstetric (Global Maternity/Obstetric [OB]) Care was Provided
  • Attachment D: Examples of Scenarios for Reporting High-Order Multiple (Triplets, Quadruplets, etc.) Births when Antepartum Care was not Provided



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)





Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)




HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

REFER TO POLICY ATTACHMENTS FOR EXAMPLES OF PROCEDURE AND MODIFIER CODING COMBINATION SCENARIOS FOR MULTIPLE BIRTHS

22: Unusual procedural services

59: Distinct procedural service



Coding and Billing Requirements


Cross References

Attachment A: Billing Requirements for Multiple Births for Professional Providers
Description: EXAMPLES OF MULTIPLE BIRTHS CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED

Attachment B: Billing Requirements for Multiple Births for Professional Providers
Description: EXAMPLES OF MULTIPLE BIRTHS CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANTEPARTUM CARE WAS NOT PROVIDED

Attachment C: Billing Requirements for Multiple Births for Professional Providers
Description: EXAMPLES OF CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC.) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED

Attachment D: Billing Requirements for Multiple Births for Professional Providers
Description: EXAMPLES OF MULTIPLE BIRTHS CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE WAS NOT PROVIDED



Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 11/12/2010
Version Issued Date: 11/12/2010
Version Reissued Date: N/A

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