3.0 POLICY
3.1 A freestanding
or institution affiliated birthing center may be considered for
status as an authorized institutional provider.
3.2 Reimbursement
for all-inclusive maternity care and childbirth services furnished
by an authorized birthing center shall be limited to the lower of
the TRICARE established all-inclusive rate or the billed charge.
3.3 The all-inclusive
rate shall include the following to the extent that they are usually
associated with a normal pregnancy and childbirth: laboratory studies,
prenatal management, labor management, delivery, postpartum management,
newborn care, birth assistant, certified nurse-midwife professional services,
physician professional services, and the use of the facility. The
rate includes physician services for routine consultation when certified
nurse-midwife is the attending professional.
Note: The initial complete newborn examination by a
pediatrician is not included in the birthing center all-inclusive
fee and is to be cost-shared as a part of the maternity episode
when performed within 72 hours of the delivery.
3.4 TRICARE maximum
allowable birthing center all-inclusive rates for services provided
prior to April 1, 2018.3.4.1 The
TRICARE maximum allowable all-inclusive rate is equal to the sum
of the CHAMPUS Maximum Allowable Charge (CMAC) for total obstetrical
care for a normal pregnancy and delivery (Current Procedural Terminology
(CPT) procedure code 59400) based on the appropriate class of the professional
provider submitting the claim plus the DHA supplied non-professional
price component amount. DHA will supply each contractor with non
professional price components for each state annually to be effective
for the forthcoming rate year (see Addendum A).
3.4.2 Claims for professional services and tests
where the beneficiary has been screened but rejected for admission
into the program, or where the woman has been admitted but is discharged from
the birthing center program prior to delivery, should be priced
as individual services and items, subject to current policies for
obstetrical care professional services and reported as appropriate
CPT procedure code with either Place
of Service code “22”
or “25”.
3.4.3 Claims from birthing centers will be processed
as outpatient hospital claims using revenue code 724 and the following
CPT procedure code with
either Place
of
Service
code “22”
or “
25”.
59400
- Obstetrical care
3.4.4 The cost-share amount for birthing
center claims is calculated using the ambulatory surgery cost-share
formula.
3.4.5 The
maximum allowable all-inclusive rate shall be updated on April 1st
each year to coincide with the Outpatient Prospective Payment System
(OPPS) quarterly update.
3.5 TRICARE maximum allowable birthing
center all-inclusive rates for services provided on or after April
1, 2018.3.5.1 The
all-inclusive rate requirement shall not preclude reimbursement
of the individual components of covered services (both professional
and non-professional) furnished by the birthing center that would
otherwise be included within the all-inclusive rate. Therefore,
birthing centers may be paid an all-inclusive rate for services
(professional and non-professional) that they actually provide. If
the birthing center only provides part of the professional services
because the beneficiary moves and gets the remaining services elsewhere,
TRICARE may pay only for that part of the services (namely, the professional
services) they provided as part of the all-inclusive rate for the
birthing center. Likewise, if the birthing center does not provide
facility services for the actual delivery, the all-inclusive rate
would not include the facility component payment.
3.5.2 The facility component of the
birthing center all-inclusive rate will be the one-day Diagnosis
Related Group (DRG) short-stay outlier for DRG 775 (uncomplicated
vaginal birth) adjusted for geographic cost variations. This facility
rate more accurately reflects the costs associated with a normal
vaginal delivery and will be consistent with TRICARE reimbursement
rates currently in use for inpatient institutional services. The
DRG zip-to-wage index files will be used for adjusting the facility component
rate for geographical labor cost variations.
3.5.3 The total all-inclusive rate
[i.e., the global maternity (CPT procedure code 59400) professional
rate plus the facility DRG 775 amount] shall only be reimbursed
if all of the maternity services (antepartum, delivery, and postpartum
services) are provided by the same birthing center.
3.5.4 The all-inclusive rate for partial
episodes of care, due in part to the high degree of mobility inherent
in military life resulting in changing providers during pregnancy,
shall be comprised of the sum of the applicable professional (CMAC)
and facility component (DRG 775) rates as reflected in the following
coding chart:
|
Coding
Used for Payment of Birthing Centers
|
|
Professional payment
|
Description
|
FACILITY PAYMENT
|
Description
|
|
59400
|
(Global
Professional Services) Obstetrical care
|
DRG
775
Short Stay Outlier (SSO)
|
Vaginal
Delivery w/o Complicating Diagnosis
|
|
Appropriate Evaluation
& Management (E/M) Codes
|
Antepartum
care only, 1-3 visits
|
No
Payment
|
|
|
59409
|
Obstetrical
care
|
DRG
775 (SSO)
|
Vaginal
Delivery w/o Complicating Diagnosis
|
|
59410
|
Obstetrical
care
|
DRG
775 (SSO)
|
Vaginal
Delivery w/o Complicating Diagnosis
|
|
59425
|
Antepartum
care only
|
No
Payment
|
|
|
59426
|
Antepartum
care only
|
No
Payment
|
|
|
59430
|
Care
after delivery
|
No
Payment
|
|
3.5.5 The
following are examples of payment of itemized services provided
by different health care providers using the above coding chart:3.5.5.1 Antepartum
Care Only: CPT codes 59425 (Antepartum care only; 4-6 visits)
and 59426 (Antepartum care only; 7 or more visits)
were created for situations such as relocation or change to another
health care provider. In these situations, all the routine antepartum
care (usually 13 visits) or global care may not be provided by the
same health care provider.Example: A beneficiary
receives her antepartum visits (12 visits) from an obstetrics and gynecology
(OBGYN) group in San Diego, CA, and is subsequently relocated to
Norfolk, VA, where she receives the remainder of her maternity care
(i.e., delivery and postpartum care) from a birthing center. The
OBGYN group would receive payment for the antepartum visits only
(CPT procedure code 59425) while the birthing center would receive
payment for the remaining professional services related to the delivery
and postpartum care (CPT procedure code 59410), along with DRG 775
for the facility delivery services.
3.5.5.2 Postpartum
Care Only: CPT procedure code 59430 (Care after delivery
Postpartum care only (separate procedure)] was created
for situations where postpartum care is not provided by the same health
care provider that performed the actual delivery. The American Congress
of Obstetricians and Gynecologists (ACOG) considers the postpartum
period to be 60 days following the date of the vaginal delivery.Example: A beneficiary
receives her antepartum visits (13 visits) and delivery from a birthing center
in Denver, CO, and is subsequently relocated to San Antonio, TX,
shortly after delivery where she receives her postpartum care from
an OBGYN group. The birthing center would be reimbursed for the
antepartum visits (CPT procedure code 59426), the professional delivery
services (CPT procedure code 59409), and the delivery facility services
(DRG 775) while the OBGYN group would receive separate payment for
the postpartum care (CPT procedure code 59430).
3.5.5.3 Vaginal
Delivery Only, No Postpartum Care: Delivery services include admission
to the birthing center facility, the admission history and physical
examination, and management of uncomplicated labor and vaginal delivery.
CPT procedure code 59409 (Obstetrical care Vaginal delivery only,
with or without episiotomy and/or forceps) was created
for delivery services only; i.e., where only the delivery component
of the maternity care is provided and antepartum and postpartum
care are performed by other health care providers.Example: A beneficiary
receives her antepartum visits/care from a birthing center in Colorado Springs,
CO, and is subsequently relocated to Augusta, GA, where she delivers
at a birthing center, and after which she moves back temporarily
to Colorado Springs to be with family and friends. She receives
her postpartum care from the birthing center in Colorado Springs.
The birthing center in Colorado Springs would receive separate payment
for the antepartum (CPT procedure code 59426) and postpartum (CPT procedure
code 59430) care, while the birthing center in Augusta, GA, would
receive payment for both the facility (DRG 775) and professional
(CPT procedure code 59409) delivery services.
3.5.6 The maximum allowable all-inclusive
component (professional and facility) rates will be updated to coincide
with the annual DRG and CMAC updates.
3.5.7 The cost-share amount for birthing
center claims for which there is a facility component (DRG 775)
will be calculated using the ambulatory surgery cost-share formula.
That is, claims from birthing centers processed as outpatient institutional
claims using Revenue Code 724 and the following CPT procedure codes
with Place of Service “25” for birthing center will
be cost-shared the same as an Ambulatory Surgery Center (ASC). Separate
cost-sharing will not be deducted for professional services as long
as there is a facility component billing (DRG 775) on the claim.
59400
- Obstetrical care
59409 - Obstetrical
care
59410 - Obstetrical
care
3.5.8 Freestanding birthing center
claims for which only the following professional services are billed
will be subject to the standard outpatient cost-share provisions;
i.e., a separate cost-share will be deducted for professional services
for which there is no corresponding non-professional (facility) component
billed on the claim.
59425 - Antepartum
care only
59426 - Antepartum care
only
59430 - Care after delivery
3.6 Extraordinary maternity care
services (services in excess of the quantity or type usually associated
with all-inclusive maternity care and childbirth service for a normal
pregnancy) may be cost- shared as part of the birthing center maternity
episode and paid as the lesser of the billed charge or the allowable
charge when the service is determined to be otherwise authorized
and medically necessary and appropriate.
3.7 Claims for birthing centers must be submitted
on a Centers for Medicare and Medicaid Services (CMS) 1450 UB-04
claim form. Claims not submitted on the appropriate claim form will
be denied.
3.8 Both the
technical and professional components of usual tests are included
in the all-inclusive rate.
3.9 Excluded services when billed separately.
99071 - Patient education materials
99078 - Group health education