3.0 POLICY
3.1 A freestanding
or institution affiliated birthing center shall 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 shall 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, shall 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
shall 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 shall 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, DHA will 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 shall not
include the facility component payment.
3.5.2 The facility component of the birthing center
all-inclusive rate shall be the one-day Diagnosis
Related Group (DRG) Short-Stay Outlier (SSO) for
DRG 775 (uncomplicated vaginal birth) adjusted for geographic cost
variations. Since DRG 775 has been deleted by the
Centers for Medicare and Medicaid Services (CMS) starting in Fiscal
Year (FY) 2019, DHA is replacing DRG 775 with the one-day SSO for
DRG 807 (uncomplicated vaginal birth without sterilization/D&C)
adjusted for geographic cost variations, effective for service dates
on or after October 1, 2018. 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 shall 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 or DRG 807 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 or DRG 807)
rates as reflected in the following coding chart:
|
Coding
Used for Payment of Birthing Centers
|
|
Professional payment
|
Description
|
FACILITY PAYMENT for service dates
Apr 1, 2018 - sep 30, 2018
|
Description
|
FACILITY Payment
for service dates on or after
Oct 1, 2018
|
Description
|
|
59400
|
(Global Professional Services) Obstetrical
care
|
DRG 775
Short Stay Outlier (SSO)
|
Vaginal Delivery
w/o Complicating Diagnosis
|
DRG
807 (SSO)
|
Vaginal
Delivery w/o Sterilization/D&C w/o Complicating Diagnosis
|
|
Appropriate Evaluation
& Management (E/M) Codes
|
Antepartum care
only, 1-3 visits
|
No Payment
|
|
No
Payment
|
|
|
59409
|
Obstetrical
care
|
DRG 775 (SSO)
|
Vaginal Delivery
w/o Complicating Diagnosis
|
DRG
807 (SSO)
|
Vaginal
Delivery w/o Sterilization/D&C w/o Complicating Diagnosis
|
|
59410
|
Obstetrical
care
|
DRG 775 (SSO)
|
Vaginal Delivery
w/o Complicating Diagnosis
|
DRG
807 (SSO)
|
Vaginal
Delivery w/o Sterilization/D&C w/o Complicating Diagnosis
|
|
59425
|
Antepartum care
only
|
No Payment
|
|
No
Payment
|
|
|
59426
|
Antepartum care
only
|
No Payment
|
|
No
Payment
|
|
|
59430
|
Care
after delivery
|
No Payment
|
|
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
(OB/GYN) 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 OB/GYN
group shall receive payment for the
antepartum visits only (CPT procedure code 59425) while the birthing
center shall receive payment for the
remaining professional services related to the delivery and postpartum
care (CPT procedure code 59410), along with DRG 775 or
DRG 807 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 OB/GYN group.
The birthing center shall 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 OB/GYN group shall 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 shall receive
separate payment for the antepartum (CPT procedure code 59426) and
postpartum (CPT procedure code 59430) care, while the birthing center
in Augusta, GA, shall receive payment
for both the facility (DRG 775 or DRG 807)
and professional (CPT procedure code 59409) delivery services.
3.5.6 The maximum allowable all-inclusive component
(professional and facility) rates shall 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
or
DRG 807)
shall 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
shall be
cost-shared the same as an Ambulatory
Surgical Center
(ASC). Separate cost-sharing
shall not
be deducted for professional services as long as there is a facility
component billing (DRG 775
or DRG 807)
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
shall be
subject to the standard outpatient cost-share provisions; i.e.,
a separate cost-share
shall 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) shall 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 shall be
submitted on a CMS 1450 UB-04 claim
form. Claims not submitted on the appropriate claim form shall 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