1.0 APPLICABILITY
This policy is mandatory for
reimbursement of services provided by either network or non-network
providers. However, alternative network reimbursement methodologies
are permitted when approved by the Defense Health Agency (DHA) and
specifically included in the network provider agreement.
2.0 POLICY
2.1 Obstetrical
services are reimbursed as an all-inclusive global maternity professional
fee which includes all professional services normally provided for
routine antepartum care, vaginal delivery (with or without episiotomy, or
forceps or breech delivery) and postpartum care.
2.2 The price for total (all-inclusive;
global) obstetric care includes all attending physician or attending Certified
Nurse Midwife (CNM) services required during the course of the maternity
episode. Incidental activity (observation, preparation, coordination,
administration) rendered by office staff in support of the obstetrical professional’s
delivery of services are included in the price.
3.0 EXCEPTIONS
3.1 Hospital-Employed
Provider
Line item
charges for covered obstetrical services of a physician or CNM employed
by:
3.1.1 A DRG-exempt hospital is reimbursed
on a billed-charge basis.
3.1.2 A DRG
hospital is reimbursed subject to the CHAMPUS Maximum Allowable
Charge (CMAC) determination.
3.2 Partial
Care Rendered
Separate
billings for antepartum care or delivery or postpartum care may
be reimbursed subject to the aggregate amount limitations for a
given segment of care prescribed in
paragraph 5.2.
3.3 Tests
3.3.1 Technical
component of tests. A separate allowance in addition to the global
fee, subject to the appropriate area prevailing profile, may be
made for the technical component of medically necessary tests provided
during the period of maternity care.
3.3.2 Test-related
professional charges. A legitimate consultation for the examination,
analysis, interpretation, or application of diagnostic or laboratory
test results by a professional other than the attending obstetrician
or attending CNM shall not be considered as included in the obstetric
global fee.
3.4 Pregnancy
Testing
A separate
allowance in addition to the global fee may be made for diagnostic
tests for determination of a pregnant condition. The test may be
cost-shared regardless of the outcome of the test.
3.5 Extraordinary Professional
Services
3.5.1 A separate allowance in addition
to the global fee, subject to the appropriate area prevailing profile, may
be made for professional services in excess of the quantity usually
associated with a normal pregnancy and delivery when the extraordinary
services are not otherwise excluded by the contractor’s medical
review.
3.5.2 The contractor shall fully
document the rationale for reimbursement of these cases.
3.5.3 Medically necessary antepartum
office visits in excess of a total number of antepartum visits equal
to 12 visits plus one weekly visit from the 37th week of gestation
through delivery, may be considered for an additional allowance
only when the contractor’s medical review confirms documented maternal
or fetal risk factors which required special management, or complications
of pregnancy.
3.5.4 Medically
necessary postpartum office visits in excess of two may be considered
for an additional allowance only for the management of a complication
of pregnancy.
4.0 POLICY CONSIDERATIONS
4.1 Common Procedure Terminology
(CPT) codes 59400 or 59510 (total care; all-inclusive care; global
care).
4.1.1 CPT codes 59400 or 59510 may
be allowed only if the billing individual professional provider,
or an alternate supervised by that provider, provided all segments
of maternity care (antepartum care, delivery and postpartum care).
4.1.2 Natural childbirth classes
and training may be allowed only when included in the charge for
CPT code 59400 (all-inclusive care).
4.1.3 Charges
for global care with and without natural childbirth classes and
training should be included in the prevailing charge database for
CPT code 59400.
4.2 Billing.
Charges for the technical and professional components of tests must
be separately identified on the maternity care bill and the number
of antepartum and postpartum office visits must be indicated.
4.3 Birthing center professional
services. Reimbursement for professional services for maternity
care and childbirth furnished by a TRICARE-authorized birthing center
is included in the birthing center all-inclusive rate.
5.0 LIMITATIONS
5.1 The billing
of separate maternity care procedures is subject to rebundling to
CPT codes 59400 or 59510 when all-inclusive maternity care was provided
by the same professional provider.
5.2 Office-based
childbirth services. The allowable charge for all-inclusive maternity
care and childbirth in a physician’s office or in a CNM’s office
is limited to the established allowable-charge for professional
services for all-inclusive maternity care plus the allowable-charges
for supplies usually associated with an in-home delivery.
6.0 EXCLUSIONS
The following CPT codes are
excluded when billed separately:
|
99071
|
Patient Education Materials
|
|
99078
|
Group Health Education
|
6.1 No technical
component of a diagnostic or laboratory test is included in the
total obstetric care price.
6.2 Test-related
charges by the attending professional. With the exception of medically
necessary ultrasounds, no separate allowance may be made for the
examination, analysis, interpretation, or application of diagnostic
or laboratory test results by the attending obstetrician or attending
CNM. These activities are considered to be the responsibility of
the attending professional and included in the global fee of the
attending obstetrical care professional. For maternity related ultrasounds,
see the TRICARE Policy Manual (TPM),
Chapter 5, Section 2.1.