Alerts

ICD-10 Diagnosis Codes that Identify Trimester and Gestational Age AND Birth Weight Requirement on UB-04 Claim Forms

1/16/2017

PDF Version

TO:  Hospitals, OB/GYNs, Nurse Midwives, Maternity Primary Contractors, FQHCs and RHCs

This ALERT updates and replaces the ALERT issued on December 14, 2016.  The changes include: a correction to the cesarean section ICD-10 code range and information, how to code the birth weight for twins or triplets and further clarifies correct coding of the diagnosis pointer/indicator referenced on the claim detail.

Effective for Dates of Service beginning January 1, 2017, and thereafter, Medicaid will require ICD-10 codes that identify the estimated weeks of gestation and trimester on a UB-04 or CMS 1500 claim form submitted for a pregnant recipient when the recipient has received any prenatal, delivery or postpartum services.  The gestational age and trimester will be required on the mother’s claim, not the newborn’s claim.  The Gestational Age Diagnosis codes are Z3A.00 through Z3A.42.  Additionally, Medicaid will require the birth weight on all applicable UB-04 claim forms associated with a delivery.  

ICD-10 Diagnosis Codes that Identify Trimester and Gestational Age

The gestational age diagnosis code and CPT procedure code for deliveries and prenatal visits must be linked by a diagnosis pointer/indicator referenced on the claim detail.  This means that the claim detail with the CPT code for delivery must have a diagnosis pointer referencing the gestational age diagnosis code.  

Gestational age diagnosis codes must be on the claim when one of the following 3 criteria are met:

1. A Professional and Outpatient Hospital claim is billed with the following delivery codes (CMS
   1500 or OP UB-04 claim form):

59400-59410

Vaginal delivery

59510-59515

Cesarean delivery

59610-59622

Delivery after previous cesarean delivery


2.  A Professional claim (CMS 1500 claim form) is billed with a pregnancy diagnosis code and procedure code listed below by a Nurse Midwife or Physicians with the specialties 316 (Family Practitioner), 318 (General Practitioner), 328 (OB-GYN): 

Pregnancy Diagnosis Codes:

Z33

Pregnant state

Z34

Encounter for supervision of normal pregnancy

Z32.01

Encounter for pregnancy test-positive

O00-O08

Pregnancy with abortive outcome

O09-O09

Supervision of high risk pregnancy

O20-O29

Other maternal disorders predominantly related to pregnancy

O30-O48

Maternal care related to the fetus and amniotic cavity and possible delivery problems


Evaluation and Management (E&M) Procedure Codes:

99201-99205

New Patent Office Visits

99211-99215

Established Patient Office Visits


3.  When an Institutional Claim (UB-04 claim form) is billed with any of the following ICD-10 procedure codes:

10D00Z0-10D07Z8

Cesarean Delivery

10E0XZZ

Vaginal Delivery


Birth Weight Requirement on Institutional Inpatient UB-04 Claim Forms

Entering the Newborn’s Birth Weight on the Newborn Inpatient Facility Claim:

If a delivery claim is indicated as resulting in twins or triplets a birth weight must be submitted for each newborn using the same criteria for a single newborn.  This policy also applies to sick and well babies.  Even if a claim is filed for a sick baby, the weight of the baby will still need to be added to the mother’s inpatient claim.

Please follow these guidelines for inpatient delivery claims
   
•  For paper claims, enter value code 54 in box 39, 40 or 41 and the newborn’s birth weight (in grams) in the corresponding amount field.
•  For electronic claims, enter the newborn’s birth weight in loop 2300, segment HI, with the qualifier BE and the value code 54 in HI01-2 and the newborn’s weight (in grams) in HI01-5.

*Please note that the newborn birth weight must be entered in the format of xxxx.xx.

UB-04 Claims with the following criteria will require birth weight in the value code:

A Claim submitted with one of the following ICD-10 Surgical Procedure:

10D00Z0-10D07Z8

Cesarean Delivery

10E0XZZ

Vaginal Delivery


A Claim submitted with one of the following ICD-10 Diagnosis Codes:

O68-O709

Deliveries with Complication

O80-O82

Encounter for Delivery


If you have any questions about this ALERT, please contact the appropriate program area contact listed below: 

Maternity Program:           Sylisa Lee-Jackson at Sylisa.Lee-Jackson@medicaid.alabama.gov
Physician Program:           Beverly Churchwell at Beverly.Churchwell@medicaid.alabama.gov
Hospital Program:             Solomon Williams at Solomon.Williams@medicaid.alabama.gov
FQHC and RHC Program:  Karen Watkins-Smith at Karen.Watkins-Smith@medicaid.alabama.gov


The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2017 American Medical Association and © 2017 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.