Notification



Notification Issue Date:



Claim Payment Policy


Title:Guidelines for Well Mother/Well Baby Visits Under the Mother's Option Program

Policy #:00.05.01e

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

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

The Company's Mother's Option Program covers Well Mother/Well Baby postpartum home care visits for the mother and newborn following inpatient hospital delivery and discharge based on length-of-stay options per the following criteria.

SHORTENED LENGTH OF STAY

UNCOMPLICATED VAGINAL DELIVERY (MEMBER DISCHARGED WITHIN THE FIRST 48 HOURS FOLLOWING DELIVERY
Managed Care Lines of Business

If desired by the member, two home care visits are covered when the member is discharged within the first 24 hours following delivery.
  • The first visit should occur within 48 hours (two days) of discharge unless refused by the member. The second visit should occur within five days after the date of discharge.
If desired by the member, one home care visit is covered when the member is discharged within the first 48 hours following delivery. This visit should occur within 48 hours (two days) of discharge.

Traditional Lines of Business

If desired by the member, one home care visit is covered when the member is discharged within the first 48 hours following delivery. This visit should occur within 48 hours (two days) of discharge.

UNCOMPLICATED CESAREAN DELIVERY (MEMBER DISCHARGED WITHIN THE FIRST 96 HOURS FOLLOWING DELIVERY
All Lines of Business

If desired by the member, one home care visit is covered when the member is discharged within the first 96 hours following delivery. This visit should occur within 48 hours (two days) of discharge.

STANDARD LENGTH OF STAY

MANAGED CARE LINES OF BUSINESS
If desired by the member, one home care visit is covered when the hospital stay is 48 hours or longer for a vaginal delivery or 96 hours or longer for a Cesarean delivery. This visit must occur within five days after the date of discharge.

TRADITIONAL LINES OF BUSINESS
Members are not eligible for Mother's Option visits. Home care visits following a standard length of stay must be preapproved for medical necessity.

The elements of a Well Mother/Well Baby visit include, but are not limited to, the following:
  • Evaluation of mother and newborn(s)
  • Recording of vital signs for mother and newborn(s)
  • Monitoring of maternal diet and newborn feeding
  • Measurement of urinary and bowel outputs for the newborn(s)
  • Collection of newborn blood for testing, as required by state law or requested by professional provider order

Members who deliver in a birthing center or electively at home are not entitled to participate in the Mother's Option Program. In such cases, the delivery provider is responsible for providing postpartum visits.

Regardless of the place of delivery, if the mother and/or newborn requires inpatient care due to complications directly relating to the pregnancy or delivery, post-discharge home care visits are based on medical necessity and therefore require precertification by the Perinatal Case Management Department.

When laboratory tests need to be collected during a Well Mother/Well Baby home care visit, the specimen is taken to any participating hospital, with the following exception:
  • For Health Maintenance Organization (HMO) members in geographic areas with a capitated laboratory program, the capitation rules apply for specimens that are not on the STAT laboratory list. The STAT laboratory list may be accessed via the Company web site.

Guidelines

This policy is consistent with state and federal mandates.

When required by state legislation, home care visits under the Mother's Option Program are available to the member within 48 hours of discharge if there is an early discharge from the hospital, regardless of whether a benefit exists.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the Mother's Option Program is a benefit for all Company products when criteria in this policy are met.

Some benefit contracts exclude maternity benefits for dependent daughters. Therefore, individual member benefits must be verified.

For all Company products, postpartum home care visits are automatic and do not require precertification when performed under the Mother's Option Program with the following clarifications:
  • For members with Comprehensive Major Medical or Traditional Hospitalization coverage with a shortened length of stay, prior notification is required to ensure proper claim processing.

The postpartum home care visits are arranged by the hospital discharge planner in the hospital in which the member delivers.

Additional home care visits needed beyond those allowed by the Mother’s Option Program require a separate precertification by the Perinatal Case Management Department and are based on medical necessity.

If the mother and/or newborn will be staying in a geographic area not supported by network providers, nonparticipating providers may be used. In such cases, precertification is required for the home care visits.

If the father is a member of a Company product, and the mother is not a member of a Company product, the Mother's Option Program is not available to the mother. However, the newborn may be entitled to a home care visit under the father's benefits. Precertification is required for this service.

If the mother is medically stable and discharged at the end of the initial 48-hour (vaginal delivery) or 96-hour (Cesarean delivery) length of stay, and the newborn is not medically stable for discharge, the mother may receive the home care visit within five days after the date of discharge. Additional home care visits provided after the newborn is discharged must be requested by the professional provider, require precertification by the appropriate department, and be based on medical necessity.

Description

The federal Newborns' and Mothers' Health Protection Act (NMHPA) of 1996, including its regulations that went into effect on January 1, 1999, requires insurers to allow a hospital stay of at least 48 hours following a vaginal delivery and at least 96 hours following a Cesarean delivery. NMHPA also allows for a shorter hospital stay if the professional provider and mother agree to an earlier discharge.

The federal NMHPA does not require follow-up visits. Some states, however, mandate expanded coverage for shorter lengths of stay. The General Assembly of the Commonwealth of Pennsylvania, for example, enacted the Health Security Act in 1996 (Act 85). In addition to minimum maternity stays, Act 85 requires coverage for at least one home health care visit within 48 hours after discharge when discharge occurs prior to 48 hours following a vaginal delivery and at least 96 hours following a Cesarean delivery.

The Mother's Option Program (Mother’s Option) is a post-delivery maternity program that allows the member and her professional provider to choose a shortened length of postpartum hospitalization stay when it is in the best interest of the member's physical and emotional needs. It also provides Well Mother/Well Baby postpartum home care visits for the mother and newborn following inpatient hospital delivery and discharge, depending on the type of delivery and length of hospital stay.

All postpartum home care visits are provided by specially trained perinatal nurses and include maternal and newborn assessment and education.
References


Advisory Committee on Infant Mortality. Promoting the Health of Newborns and Mothers through Postpartum Services: Mandated by the Newborns’ and Mothers’ Health Protection Act of 1996 (Public Law 104-204, Section 606). December 2001. Available at: http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/About/postpartum.pdf. Accessed July 24, 2018.

American Academy of Pediatrics Committee on Fetus and Newborn. Policy Statement—Hospital Stay for Healthy Term Newborns. Pediatrics. 2010;125(2):405-409. Reaffirmed October 2014. Available at: http://pediatrics.aappublications.org/content/125/2/405. Accessed July 24, 2018.

Benitz WE; Committee on Fetus and Newborn, American Academy of Pediatrics. Hospital Stay for Healthy Term Newborn Infants. Pediatrics. 2015;135(5):948-53. Available at: http://pediatrics.aappublications.org/content/pediatrics/early/2015/04/21/peds.2015-0699.full.pdf. Accessed July 24, 2018.

Brown S, Small R, Argus B, et al. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews 2002, Issue 3.

Company Benefit Contracts.

Company Provider Manual. Available at:http://provcomm.ibx.com/ProvComm/ProvComm.nsf/0/b3fa407e35a8d83d85257d800049c931/$FILE/Provider_Manual_FINAL_ibc_20180711.pdf. Accessed July 24, 2018.

General Assembly of the Commonwealth of Pennsylvania. Health Security Act. Jul. 2, 1996, P.L. 514, No. 85. Available at: http://www.legis.state.pa.us/WU01/LI/LI/US/HTM/1996/0/0085..HTM. Accessed July 24, 2018.

Newborns' and Mothers' Health Protection Act, 1996. Title 42, Chapter 6A.

NJ Rev Stat 17B:26-2.1k (2017) as amended by Public Law 1995, c. 138, s. 1. Coverage of birth and natal care; hospital insurance policy.

NJ Stat Ann 17:48-6l. as amended by Public Law 1995, c. 138, s 4. Coverage of birth and natal care; hospital service corporation.

Pennsylvania Health Care Cost Containment Council (PHC4). Minimum maternity stay legislation: Changes in hospital length-of-stay for child birth. [PHC4 Web site]. October 1999. Available at: http://www.phc4.org/reports/cdlos/docs/reportCdlos1999.pdf. Accessed July 24, 2018.

US General Accounting Office Health, Education, and Human Services Division. Maternity Care: Appropriate Follow up Services Critical with Shorter Hospital Stays. September 1996. Available at: http://www.gpo.gov/fdsys/pkg/GAOREPORTS-HEHS-96-207/pdf/GAOREPORTS-HEHS-96-207.pdf. Accessed July 24, 2018.




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)

N/A


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)

N/A


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)

O80 Encounter for full-term uncomplicated delivery

O82 Encounter for cesarean delivery without indication

Z39.2 Encounter for routine postpartum follow-up



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)



THE FOLLOWING CODE IS USED TO REPRESENT ROUTINE POSTPARTUM FOLLOW-UP (WELL MOTHER/WELL BABY) VISIT:

0551 Skilled nursing - visit charge

Coding and Billing Requirements


Cross References


Policy History

Revisions from 00.05.01e:
08/29/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Well Mother/Well Baby Visits Under the Mother's Option Program.

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 09/09/2016
Version Issued Date: 09/09/2016
Version Reissued Date: 08/29/2018

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.