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Date Printed: June 23, 2017: 11:38 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

03-59000-04

Original Effective Date: 01/27/00

Reviewed: 03/25/09

Revised: 01/01/17

Subject: Complications of Pregnancy

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Complications of pregnancy are medical conditions experienced during pregnancy, which may seriously jeopardize the health of the pregnant mother or unborn (fetus, infant).

POSITION STATEMENT:

NOTE: Review member’s contract language in making a coverage decision about coverage for complications of pregnancy.

Complications of pregnancy meet the definition of medical necessity when the condition is diagnosed as a separate condition from the pregnancy. Coverage for complications of pregnancy is limited to covered services to treat the condition caused by the complication.

BILLING/CODING INFORMATION:

CPT Coding:

Vaginal Delivery, Antepartum and Postpartum Care

59400

Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

59409

Vaginal delivery only (with or without episiotomy and/or forceps)

59410

Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

59412

External cephalic version, with or without tocolysis

59414

Delivery of placenta (separate procedure)

Cesarean Delivery

59510

Routine obstetric care including antepartum care cesarean delivery, and postpartum care

59514

Cesarean delivery only

59515

Cesarean delivery only; including postpartum care

HCPCS Coding:

G9361

Medical indication for induction [documentation of reason(s) for elective delivery (c-section) or early induction (e.g., hemorrhage and placental complications, hypertension, preeclampsia and eclampsia, rupture of membranes-premature or prolonged maternal conditions complicating pregnancy/delivery, fetal conditions complicating pregnancy/delivery, late pregnancy, prior uterine surgery, or participation in clinical trial)]

REIMBURSEMENT INFORMATION:

Reimbursement for a vaginal delivery (59400, 59409, 59410, 59414, 59610, 59612, and 59614) performed on the same day as a cesarean section (59510, 59515, 59618, 59620, and 59622) is based on medical review of documentation of the medical indications and physician’s operative report.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Abortion: the premature expulsion from the uterus of the products of conception of the embryo, or nonviable fetus. Classic symptoms usually present are: uterine contractions, uterine hemorrhage, softening and dilatation of the cervix, and presentation or expulsion of all or part of the products of conception.

Antepartum: occurring before the onset of labor.

Ectopic pregnancy: development of the fertilized ovum outside of the uterine cavity (extrauterine pregnancy).

Hydatidiform mole: abnormal pregnancy, which results in a mass or cysts.

Hyperemesis gravidarum: pernicious (fatal) vomiting of pregnancy/excessive vomiting.

Missed abortion: retention of the products of conception of the embryo, or of a nonviable fetus.

Polyhydramnios: excess of amniotic fluid.

Postpartum: occurring after childbirth or delivery.

Puerperium: the period from the end of the third stage of labor until involution of the uterus is complete, usually lasting 3 to 6 weeks.

Spontaneous abortion: abortion occurring naturally.

RELATED GUIDELINES:

None applicable.

OTHER:

Claims submitted with diagnoses that require Medical Review and diagnoses that are not listed requires review of the following information:

Physician history and physical, physician operative report, physician procedure notes, ante partum, and, postpartum records, and plan of treatment.

LOINC Codes:

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative note

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician procedure note

11505-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note (i.e., ante partum and postpartum records)

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Labor and Delivery records

15508-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REFERENCES:

  1. American College of Obstetricians and Gynecologists (ACOG) News Release-Research Finds 40% of Pregnancy-Related Deaths Potentially Preventable, 11/30/05.
  2. American College of Obstetricians and Gynecologists (ACOG), Maternal Complications Associated With Multiple Cesarean Deliveries, 07/06.
  3. American College of Obstetrics and Gynecologists, 01/00.
  4. Bergel E, Carroli G, Althabe F, Ambulatory Versus Conventional Methods for Monitoring Blood Pressure During Pregnancy.
  5. Caughey AB, Musci TJ. Complications of Term Pregnancies Beyond 37 Weeks of Gestation. American College of Obstetricians and Gynecologists 2004; 103(1): 57-62.
  6. Hayes, Inc., Three-Dimensional and Four-Dimensional Ultrasound for Diagnosis of Fetal Head Abnormalities, update 01/07/07.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/25/09.

GUIDELINE UPDATE INFORMATION:

01/27/00

Medical Coverage Guideline developed.

03/15/02

Bi-annual review of MCG; no changes.

10/01/02

Revised ICD-9 code range for ectopic pregnancy.

03/15/04

Annual review. Deleted bed rest from the “when services are covered”. Deleted diagnoses code range 669.22 – 669.44 from the medically necessity list and added to the list of diagnoses that require medical review.

08/15/06

Clarified coding for other complications of labor and delivery. Updated references.

01/01/07

Added “Medical” and “Reimbursement Guideline” to title. Updated description section. Updated ICD-9 diagnoses that do not require medical review and diagnoses that require medical review. Added diagnosis codes: 649.10 – 649.14, 649.20 – 649.24, 649.30 – 649.34, 649.40 – 649.44, 649.50 – 649.53, and 649.30 – 649.64. Revised other section. Updated references.

02/15/07

Revised ICD-9 diagnoses codes. Under the section for diagnoses that do not require medical review: Deleted 634.11 – 634.91, 641.80, 674.40, 674.42, and 674.44. Corrected typo for 659.32 (change 5th digit to 1 [659.31]). Under the section for diagnoses that require medical review: Deleted 634.00 – 634.92, 637.00 – 637.92, 638.0 – 638.9. Added 643.20, 643.21, 643.23, 651.23, and 665.44. Deleted extra 652.03.

06/15/07

Reformatted guideline.

08/15/07

Annual review, coverage statement maintained, references updated.

04/15/09

Annual review. Revised description section and position statement. Updated ICD-9 diagnoses codes and descriptors. Updated references.

03/15/10

ICD-9 code update, deleted 651.13 from diagnoses that do not require medical review. Added 651.13 to diagnoses that require medical review.

08/15/10

ICD-9 code updates; added 640.90, 640.91, 640.93, 678.00, 678.01, 678.03, 678.10, 678.11, 678.13, 679.00, 679.01, 679.02, 679.03, 679.04, 679.10, 679.11, 679.12, 679.13, 679.14, 641.00, 641.01, 641.03, 641.80, 641.81, 641.83, 641.90, 641.91, 641.93, 646.12, 646.22, 647.02, 647.12, 647.22, 647.32, 647.42, 647.52, 647.62, 647.82, 647.92, 648.71, 649.71, 649.72, 656.20, 656.21, 656.23, 664.60, 664.61, 664.64, 665.74, 671.04, 671.10 – 671.14, 671.20 – 671.24, 671.30, 671.31, 671.33, 671.40, 671.42, 674.44, 671.50 – 671.54, 671.80, 671.84, 671.90, 671.91, 671.93, 675.04,675.10 – 675.14, 675.20 – 675.24, 675.80 – 675.84, 675.90 – 675.93, and 676.00 – 676.94.

02/15/11

Revision; related ICD-10 codes added.

07/15/11

Revision; formatting changes.

10/01/11

Revision; related ICD-9 code added 649.81 and 649.82, and deleted 631.

04/01/12

ICD-9 code updates; deleted ICD-9 codes that do not require medical review.

05/11/14

Revision: Program Exceptions section updated.

05/15/14

Code update; added 654.23.

07/01/14

Quarterly HCPCS update; added G9361.

07/30/15

Revised O36 1st digit; changed 0 to O.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision; updated billing/coding information section.

01/01/17

Annual HCPCS code update. Revised G9361 code descriptor.

Date Printed: June 23, 2017: 11:38 AM