Notification



Notification Issue Date:



Claim Payment Policy


Title:Guidelines for Home Care Visits Following Inpatient Maternity Stay

Policy #:00.05.01f

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 covers home care visits following inpatient maternity stays. The number of visits covered, as well as the timing of the visit(s) after discharge, is based on length of stay and the type of delivery (i.e., vaginal or cesarean).

Following a one-day hospital stay for an uncomplicated vaginal delivery, two home care visits are covered. The first visit should occur within 48 hours of discharge. The second visit should occur within five days after discharge.

Following a two-day hospital stay for an uncomplicated vaginal delivery, one home care visit is covered. This visit should occur within 48 hours after discharge.

Following a hospital stay of up to four days for an uncomplicated cesarean delivery, one home care visit is covered. This visit should occur within 48 hours after discharge.

Following a hospital stay of greater than two days for a vaginal delivery, or greater than four days for a cesarean delivery, one home care visit is covered. This visit must occur within five days after discharge.

If the mother is medically stable and discharged within the length of stays described above, and the newborn is not medically stable for discharge, the mother's home care visit(s) are covered. The visit(s) must occur within five days after the date of the mother's discharge. Additional home care visits provided after the newborn is discharged will be based on medical necessity.

Regardless of the place or type 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 covered based on medical necessity.
Guidelines

This policy is consistent with state and federal mandates.

Description

When a shortened length of post-delivery hospitalization is determined by the mother and the professional provider to be in the best interest of the mother's and newborn's needs, home care visits are covered based upon the type of delivery and length of hospital stay. Home care visits provide for ongoing postpartum needs following inpatient hospital delivery and discharge.
References

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 October 4, 2019.


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 October 4, 2019.

Company Benefit Contracts.

Company Provider Manuals.

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 October 4, 2019.

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 October 4, 2019.

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 May 29, 2019.



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)

0551 Skilled nursing - visit charge

Coding and Billing Requirements


Cross References


Policy History

Revisions from 00.05.01f:
12/16/2019This version of the policy becomes effective 12/16/2019. This policy update maintains the Company’s continuing position on home care visits following an inpatient maternity stay.

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: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A

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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.