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