Texas Medicaid announces changes to obstetrical delivery procedure codes, elective deliveries

posted 08.09.11

Effective Oct. 1, 2011, Texas Medicaid is changing its benefit criteria for obstetric deliveries and will deny claims for any induction or cesarean delivery before 39 weeks gestation if not medically necessary and properly documented.

The change to obstetric procedure codes affects the following: 59409, 59410, 59514, 59515, 59612, 59614, 59620, and 59622. Physicians using these codes must include one of the modifiers listed below or else the claim will be denied.

• U1 — Medically necessary delivery prior to 39 weeks of gestation
• U2 — Delivery at 39 weeks of gestation or later
• U3 — Non-medically necessary delivery prior to 39 weeks of gestation

Texas Medicaid will restrict any caesarean section, labor induction, or any delivery following induction of labor to one of the following additional criteria.

• Gestational age of the fetus should be determined to be at least 39 weeks or fetal lung maturity must be established before delivery.
• When the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery.

Claims for cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to 39 weeks of gestation and are not considered medically necessary—because the medical documentation does not support that decision—will be denied. Records will be subject to retrospective review. Payments made for non-medically-indicated caesarean sections, labor inductions, or any deliveries following labor induction, which fail to meet medical necessity criteria, will be subject to recoupment. Recoupment may apply to all services related to the delivery, including additional physician fees and the hospital fees.

The new policy was passed through in the 82nd Texas Legislature and is a primary initiative of the Healthy Texas Babies project. The original deadline of Sept. 1 was delayed to give physicians and hospitals more time to implement the new policy. According to Texas Medicaid, the goal is to help guide providers toward these practice recommendations by the American Congress of Obstetricians and Gynecologists and other professional organizations, and to reduce morbidity in the neonates from birth trauma and fetal immaturity and in the mothers from the consequences of failed inductions.

For more information, visit the Texas Medicaid and Healthcare Partnership website or call the TMHP Contact Center at (800) 925-9126.