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