UPDATE ON THE CORRECT CODING OF GEORGIA MEDICAID’S ELECTIVE C/SECTION RATE AND PAYMENT POLICY
Effective December 1, 2017, the Department of Community Health, Medicaid Division, will enforce a coding policy for reporting Elective Cesarean Sections rates. In collaboration, the 4 Care Management Organizations (CMOs) developed coding guidance that providers are to utilize for appropriate coding of cesarean sections delivery claims.
Based on providers’ coding noted on some claims and chart reviews, 403 cesarean sections claims for one CMO in one calendar year were submitted WITHOUT a specific diagnosis code and with only a LMP/EDC in field 14 of the CMS 1500 claim form. The absence of a diagnosis code results in a default to an “ELECTIVE” designation. When 358 of the 403 charts were manually reviewed, 356 charts were documented as medically indicated cesarean sections and 2 were vaginal births that were miscoded. Claims must reflect an actual reflection of the care provided. Incorrect or incomplete coding of cesarean sections claims have created an incorrect Elective Cesarean Sections rate in our state. Please inform your staff that proper coding of the appropriate ICD-10 diagnosis code on cesarean sections delivery claims will avoid future inconvenience and any delay in payments.
As a reminder, per Medicaid policy, professional 1500 claims submitted without a DIAGNOSIS code and an LMP/EDC for ANY labor inductions or cesarean sections on or before 39 weeks gestation that are not properly documented as medically necessary will be DENIED. ALL Medicaid practitioners’ claims for Elective inductions/C-sections must include the LMP/EDC/EDD in field locator 14 of the CMS 1500 paper/electronic form.
Practitioners are to continue billing the following obstetric procedure codes on their 1500 professional claim forms for payment: 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, and 59622, along with one of the three modifiers (UB, UC, UD) appended to the billed delivery procedure code.
If you should need further information or have specific billing and or coding questions related to this updated policy, please contact your CMO network provider representative.
Thank you for your continued participation in the GA Medicaid program.
