Beginning October 1, Georgia Medicaid will deny both professional and facility claims submitted for early elective delivery (EED) labor inductions or Cesarean sections (C-sections) on or before 39 weeks gestation if documentation does not show them to be medically necessary. According to a memo to providers from the Georgia Department of Community Health (DCH), Medicaid Division, “Medicaid delivery claims submitted, with dates of service on or after October 1, 2013, from enrolled hospitals and practitioners for elective inductions or deliveries must adhere to this EED policy.”
The DCH this year changed its policy regarding medically unnecessary EED based on research conducted by the American College of Obstetricians and Gynecologists (ACOG). This research suggests that babies born before 39 weeks of gestation are at increased risk for developing health problems, including low birth weight, respiratory distress syndrome, physiological and metabolic immaturity, feeding problems, and sepsis. As a result, these infants have higher rates of morbidity (e.g., birth trauma and fetal immaturity) and mortality.
Medicaid-enrolled providers that perform an EED will be required to append designated modifiers to the delivery claim and complete the ACOG Patient Safety Checklist (or comparable form) when scheduling an induction of labor or planned C-section for deliveries less than 39 weeks of gestation. The billable CPT procedure codes that require appended modifiers are 59400, 59409, 59410, 59414, 59510, 59514, 59515, 59618, 59612, 59620, and 59622. The required modifiers for obstetrics services are below:
UB—Medically necessary delivery prior to 39 weeks of gestation
UC—Delivery at 39 weeks of gestation or later
UD—Non-medically necessary delivery prior to 39 weeks of gestation
The impact of the EED policy will be monitored by the Centers for Medicare & Medicaid Services through Georgia’s reporting of the EED measure 14 in the Initial Core Set of Health Care Quality Measures for Medicaid Eligible Adults.
Hospitals and practitioners may appeal denials by submitting claims with clinical justification and proper documentation from the hospital and the practitioner to the Georgia Medical Care Foundation.
