December 14, 2016

State of Alabama
Press Release: Medicaid

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

PDF Version

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

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

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): 



Vaginal delivery


Cesarean delivery


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:



Pregnant state


Encounter for supervision of normal pregnancy


Encounter for pregnancy test-positive


Pregnancy with abortive outcome


Supervision of high risk pregnancy


Other maternal disorders predominantly related to pregnancy


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


Evaluation and Management (E&M) Procedure Codes:



New Patent Office Visits


Established Patient Office Visits

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

      procedure codes:  



Cesarean Delivery


Vaginal Delivery

Birth Weight Requirement on Institutional Inpatient UB-04 Claim Forms

Entering the Newborn’s Birth Weight on the Newborn Inpatient Facility 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 birthweight in the value code:


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


Cesarean Delivery


Vaginal Delivery


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


Deliveries with Complication


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

Physician Program:  Beverly Churchwell at

Hospital Program:  Solomon Williams at

FQHC and RHC Program:  Karen Watkins-Smith at

The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2016 American Medical Association and © 2016 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.


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