April 13, 2017

State of Alabama
Press Release: Medicaid

ICD-10 Diagnosis Codes that identify weeks gestation of pregnancy and birth weight requirement when billing a delivery CPT Procedure Code

PDF Version

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

This ALERT updates and replaces the ALERT issued on January 13, 2017.  The change includes the reporting range for Weeks Gestation of Pregnancy Diagnosis Codes.

Effective for Dates of Service beginning January 1, 2017, and thereafter, Medicaid required a Weeks Gestation of Pregnancy Diagnosis Code and a birth weight on delivery claims billed on an UB-04 or CMS 1500 Claim Form if a recipient has received any prenatal, delivery or postpartum services.

If delivery or prenatal visit CPT Procedure Codes are billed on an UB-04 or CMS 1500 Claim Form, an ICD-10 Diagnosis Code must be appended to identify the weeks gestation of pregnancy. The weeks gestation of pregnancy IS required on the mother’s claim, NOT the newborn’s claim.  

The Weeks Gestation of Pregnancy 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 Procedure Code for a delivery must have a Diagnosis Pointer referencing the Weeks Gestation of Pregnancy Diagnosis Code.  

Claims that Require Gestational Age Diagnosis Codes


If any of the following claim types are billed, a Weeks Gestation of Pregnancy Diagnosis Code must be appended to the claim. The Weeks Gestation of Pregnancy Diagnosis Codes are Z3A.00 through Z3A49 and are listed below in Table 1.0.

1.  A CMS 1500 or UB-04 claim (Professional and Outpatient Hospital claims) using the following delivery codes:  
59400-59410       Vaginal delivery
59510-59515       Cesarean delivery
59610-59622       Delivery after previous cesarean delivery

2.  A Nurse Midwife or Physician with specialties 316 (Family Practitioner), 318 (General Practitioner), 328 (OB-GYN) billing Office Visits Codes and Professional claims using a CMS 1500 Claim Form.

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

99201-99205       New Patent Office Visits
99211-99215       Established Patient Office Visits

3.  An Institutional Inpatient UB-04 Claim Forms using any of the following ICD-10 Procedure Codes:  
 
10D00Z0-10D0728          Cesarean Delivery
10E0XZZ    Vaginal           Delivery

Birth Weight Requirement on Institutional Inpatient UB-04 Claim Forms

An Institutional Inpatient UB-04 delivery claim requires a birthweight when an ICD-10 Surgical Procedure Code or an ICD-10 Diagnosis Code indicating delivery is submitted. *This birthweight requirement only applies to deliveries with a gestational age of 20 weeks or greater (Z3A.20 – Z3A.49). If a delivery claim is indicated as resulting in twins or triplets, a birthweight must be submitted for each newborn using the same criteria for a single newborn. This policy also applies to sick and well babies.  

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.
•  Newborn birth weight must be entered in the format of xxxx.xx.

The claim form must contain one of the following ICD-10 Surgical Procedure Code;

10D00Z0-10D07Z8          Cesarean Delivery
10E0XZZ                           Vaginal Delivery

        OR

One of the following ICD-10 Diagnosis Codes;

O68-O709                       Deliveries with Complication
O80-O82                         Encounter for Delivery

       *AND

One of the following Weeks Gestation of Pregnancy Diagnosis Codes listed in Table 1.0.

Table 1.0
Z3A20      20 WEEKS GESTATION OF PREGNANCY        Z3A32      32 WEEKS GESTATION OF PREGNANCY
Z3A21      21 WEEKS GESTATION OF PREGNANCY        Z3A33      33 WEEKS GESTATION OF PREGNANCY
Z3A22      22 WEEKS GESTATION OF PREGNANCY        Z3A34      34 WEEKS GESTATION OF PREGNANCY
Z3A23      23 WEEKS GESTATION OF PREGNANCY        Z3A35      35 WEEKS GESTATION OF PREGNANCY
Z3A24      24 WEEKS GESTATION OF PREGNANCY        Z3A36      36 WEEKS GESTATION OF PREGNANCY
Z3A25      25 WEEKS GESTATION OF PREGNANCY        Z3A37      37 WEEKS GESTATION OF PREGNANCY
Z3A26      26 WEEKS GESTATION OF PREGNANCY        Z3A38      38 WEEKS GESTATION OF PREGNANCY
Z3A27      27 WEEKS GESTATION OF PREGNANCY        Z3A39      39 WEEKS GESTATION OF PREGNANCY
Z3A28      28 WEEKS GESTATION OF PREGNANCY        Z3A40      40 WEEKS GESTATION OF PREGNANCY
Z3A29      29 WEEKS GESTATION OF PREGNANCY        Z3A41      41 WEEKS GESTATION OF PREGNANCY
Z3A30      30 WEEKS GESTATION OF PREGNANCY        Z3A42      42 WEEKS GESTATION OF PREGNANCY    
Z3A31      31 WEEKS GESTATION OF PREGNANCY        Z3A49      GREATER THAN 42 WEEKS GESTATION
                                                                                                        OF PREGNANCY

If you have any questions about this ALERT, please contact the appropriate program area 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.



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