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) 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 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 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 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 04/01/18 - 09/30/18
|
Description
|
FACILITY Payment for service
dates on or after 10/01/18
|
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 code 59425) while the birthing center shall receive payment
for the remaining professional services related to the delivery
and postpartum care (CPT code 59410), along with DRG 775 or DRG
807 for the facility delivery services.
3.5.5.2 Postpartum Care Only: CPT 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 calendar 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 code 59426), the professional delivery services
(CPT code 59409), and the delivery facility services (DRG 775) while
the OB/GYN group shall receive separate payment for the postpartum
care (CPT 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 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 code 59426) and postpartum (CPT 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 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
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