Resource Home Births

Lori · Sep 24, 2021

Postpartum

Newborn

EPA criteria for drugs not billable by licensed
midwives

To use an EPA to bill procedure codes 90371, J2540, S0077, J0290, J1364, the licensed midwife
must meet all of the following:
 Obtained physician or standing orders for the administration of the drug listed as not
billable by a licensed midwife.
 Placed the physician or standing orders in the client’s file.
 Will provide a copy of the physician or standing orders to the agency upon request.
Note: Enter the EPA number (870000690) in field 23 (Prior Authorization) on the
CMS-1500 claim form. Do not handwrite the EPA number on the claim.

Lori · Sep 24, 2021

Routine Prenatal Care

Note: CPT codes 59425, 59426, or E&M codes 99211-99215 with normal pregnancy diagnoses may not be billed in combination during the entire pregnancy. Do not bill the agency for prenatal care until all routine prenatal services are complete.

Additional monitoring

Note: Midwives who provide increased monitoring for routine prenatal care may bill using the appropriate E&M code with modifier TH.

Delivery (intrapartum)

Postpartum

Lori · Sep 24, 2021

Labor management

Bill these codes only when the client labors at the birthing center or at home and is then
transferred to a hospital, another provider delivers the baby, and a referral is made during active
labor. The diagnoses must be related to complications during labor and delivery. The delivering
physician may not bill for labor management. Prolonged services must be billed on the same
claim form as E&M codes along with modifier TH and one of the diagnoses listed above (all
must be on each detail line of the claim form).

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Other Codes

Lori · Sep 24, 2021

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Facility Fee Payment

Note: Payments for facility use are limited to only those providers who have been approved by the agency. When modifier SU is attached to the delivery code, it is used to report the use of the provider’s facility or equipment only.

Home Birth Kit

What does global (total) obstetrical care include?

Global obstetrical (OB) care (CPT code 59400) includes:

 Routine prenatal care in any trimester.
 Delivery.
 Postpartum care.
If you provide all of the client’s prenatal care, perform the delivery, and provide the postpartum care,
you must bill using the global OB procedure code.

Note: Bill the global obstetric procedure code if you performed all of the services and no
other provider is billing for prenatal care, the delivery, or postpartum care.
If you provide all or part of the prenatal care and/or postpartum care but you do
not perform the delivery, you must bill the agency for only those services provided using the
appropriate prenatal and/or postpartum codes. In addition, if the client obtains other medical
coverage or is transferred to an agency-contracted managed care organization (MCO) during
pregnancy, you must bill for only those services provided while the client is enrolled with
agency fee-for-service.

What does routine prenatal care include?

Prenatal care includes:

 Initial and subsequent history.
 Physical examination.
 Recording of weight and blood pressure.
 Recording of fetal heart tones.
 Routine chemical urinalysis.
 Maternity counseling, such as risk factor assessment and referrals.
Necessary prenatal laboratory tests may be billed in addition to prenatal care, except for
dipstick tests (CPT codes 81000, 81002, 81003, and 81007).
In accordance with CPT guidelines, the agency considers routine prenatal care for a normal,
uncomplicated pregnancy to consist of:
 Monthly visits up to 28 weeks gestation.
 Biweekly visits to 36 weeks gestation.
 Weekly visits until delivery.
(approximately 14 prenatal visits).

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Note: Do not bill using CPT codes 59425, 59426, and E&M codes 99211-99215 with normal pregnancy diagnoses in combination with each other during the same pregnancy. Do not bill the agency for prenatal care until all prenatal services are complete.

When an eligible client receives services from more than one
provider,

the agency reimburses each provider for the
services furnished

Example: For a client being seen by both a midwife and a physician, the agency’s
reimbursement for the co-management of the client would be as follows:

 The physician would be paid for the consult office visits.
 The midwife would be paid for the prenatal visits.

Is obstetrical care allowed to be unbundled?

In the situations described below, you may not be able to bill the agency for global OB care. In these
cases, it may be necessary to unbundle the OB services and bill the prenatal, delivery, and
postpartum care separately, as the agency may have paid another provider for some of the client’s
OB care, or another insurance carrier may have paid for some of the client’s OB care.

When a client transfers to your practice late in the
pregnancy

 Do not bill the global OB package. Bill the prenatal care, delivery, and postpartum care
separately if the client has had prenatal care elsewhere. The provider who had been providing
the prenatal care prior to the transfer bills for the services performed. Therefore, if you bill
the global OB package, you would be billing for some prenatal care that another provider has
claimed.

 If the client did not receive any prenatal care prior to coming to your office, bill the global
OB package. In this case, you may actually perform all of the components of the global
OB package in a short time. The agency does not require you to perform a specific
number of prenatal visits in order to bill for the global OB package.

If the client moves to another provider (not associated with
your practice), moves out of your area prior to delivery, or
loses the pregnancy

Bill only those services you actually provide to the client.

If the client changes insurance during pregnancy

When a client changes from one agency-contracted MCO to another, bill those services that were
provided while the client was enrolled with the original MCO to the original carrier, and those
services that were provided under the new coverage to the new MCO. You must unbundle the
services and bill the prenatal, delivery, and postpartum care separately.
Often, a client will be eligible for fee-for-service at the beginning of pregnancy, and then be
enrolled in an agency-contracted MCO for the remainder of pregnancy. The agency is
responsible for reimbursing only those services provided to the client while the client is on feefor-service. The MCO reimburses for services provided after the client is enrolled with the MCO.

Coding for prenatal care only

If it is necessary to unbundle the global package and bill separately for prenatal care, bill one of
the following:
 If the client had a total of one to three prenatal visits, bill the appropriate level of E&M
service with modifier TH for each visit with the date of service the visit occurred and
the appropriate diagnosis.

Modifier TH: Obstetrical treatment/service, prenatal or postpartum

If the client had a total of four to six prenatal visits, bill using CPT code 59425 with a one
(1) in the units box. Bill the agency using the date of the last prenatal visit in the to and
from fields.
 If the client had a total of seven or more visits, bill using CPT code 59426 with a one (1)
in the units box. Bill the agency using the date of the last prenatal visit in the to and from
fields fo the form.
Do not bill prenatal care only codes in addition to any other procedure codes that include
prenatal care (i.e. global OB codes).
When billing for prenatal care, do not bill using CPT E/M codes for the first three visits, then
CPT code 59425 for visits four through six, and then CPT code 59426 for visits seven and on.
These CPT codes are used to bill only the total number of times you saw the client for all
prenatal care during pregnancy, and may not be billed in combination with each other during the
entire pregnancy period.
Note: Do not bill the agency until all prenatal services are complete.

Coding for deliveries

If it is necessary to unbundle the OB package and bill for the delivery only, bill the agency using
one of the following CPT codes:
• 59409 (vaginal delivery only)
• 59514 (cesarean delivery only)
• 59612 [vaginal delivery only, after previous cesarean delivery (VBAC)]
• 59620 [cesarean delivery only, after attempted vaginal delivery after previous cesarean
delivery (attempted VBAC)]
If a provider does not furnish prenatal care, but performs the delivery and provides postpartum
care, bill the agency one of the following CPT codes:
• 59410 (vaginal delivery, including postpartum care)
• 59515 (cesarean delivery, including postpartum care)
• 59614 (VBAC, including postpartum care)
• 59622 (attempted VBAC, including postpartum care)

Coding for postpartum care only

If it is necessary to unbundle the global OB package and bill for postpartum care only, you must
bill the agency using CPT code 59430 (postpartum care only).

If you provide all of the prenatal and postpartum care, but do not perform the delivery, bill the
agency for the prenatal care using the appropriate coding for prenatal care (see Authorization),
along with CPT code 59430 (postpartum care only).
Do not bill CPT code 59430 (postpartum care only) in addition to any procedure codes that
include postpartum care.
Note: Postpartum care includes office visits for the six-week period after the
delivery and includes family planning counseling.

Lori · Sep 24, 2021

Additional monitoring for high-risk conditions

When providing increased monitoring for the conditions listed below in excess of the CPT
guidelines for normal prenatal visits, bill using E&M codes 99211-99215 with modifier TH. The
office visits may be billed in addition to the global fee only after exceeding the CPT guidelines
for normal prenatal care (i.e., monthly visits up to 28 weeks gestation, biweekly visits to 36
weeks gestation, and weekly visits until delivery).

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If the client has one of the conditions listed above, the provider is not automatically entitled to additional payment. In accordance with CPT guidelines, it must be medically necessary to see the client more often than what is considered routine prenatal care in order to qualify for additional payments. The additional payments are intended to cover additional costs incurred by the provider as a result of more frequent visits. Note: Licensed midwives are limited to billing for certain medical conditions (see Prenatal Management/Consultation and Referral) that require additional monitoring under this program.

Labor management

Providers may bill for labor management only when another provider (outside of your group
practice) performs the delivery. If you performed the entire prenatal care for the client, attended
the client during labor, delivered the baby, and performed the postpartum care, do not bill the
agency for labor management. These services are included in the global OB package.

However, if you performed all of the client’s prenatal care and attended the client during labor,
but transferred the client to another provider (outside of your group practice) for delivery, you
must unbundle the global OB package and bill separately for prenatal care and the time spent
managing the client’s labor. The client must be in active labor when the referral to the delivering
provider is made.

To bill for labor management in the situation described above, bill the agency for the time spent
attending the client’s labor using the appropriate CPT E&M codes 99211-99215 (for labor
attended in the office) or 99347-99350 (for labor attended at the client’s home). In addition, the
agency will reimburse providers for up to three hours of labor management using prolonged
services CPT codes 99354-99355 with modifier TH. Reimbursement for prolonged services is
limited to three hours per client, per pregnancy, regardless of the number of calendar days a
client is in labor, or the number of providers who provide labor management. Labor management
may not be billed by the delivering provider, or by any provider within the delivering provider’s
group practice.

Note: The E&M code and the prolonged services code must be billed on the
same claim form

Note: The E&M code and the prolonged services code must be billed on the same claim form.

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Does the agency pay for newborn screening tests?

The midwife or physicians will collect the blood for the newborn screening and send it to DOH.
DOH will bill the agency for payment of HCPCS code S3620. The newborn screening panel
includes:
 Biotinidase deficiency.
 Congenital adrenal hyperplasia (CAH).
 Congenital hypothyroidism.
 Homocystinuria.
 Phenylketonuria (PKU).
 Galactosemisa.
 Hemoglobinopathies.
 Homocystinuria.
 Maple Syrup Urine Disease (MSUD).
 Medium chain acyl-CoA dehydrogenase deficiency (MCAD deficiency).
 Severe combined immunodeficiency (SCID).
Note: Payment includes two tests for two different dates of service, allowed once
per newborn. Do not bill HCPCS code S3620 if the baby is born in the hospital.
This code is only for outpatient services in birthing centers, physician offices, and
homes in which midwives provide home births.

Note: Payment includes two tests for two different dates of service, allowed once
per newborn. Do not bill HCPCS code S3620 if the baby is born in the hospital.
This code is only for outpatient services in birthing centers, physician offices, and
homes in which midwives provide home births.

How are home-birth supplies billed?

Home-birth supplies are billed using HCPCS code S8415. Payment is limited to one per client, per pregnancy.

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Are medications billed separately?

Certain medications can be billed separately and are listed on the fee schedule. Some of the
medications listed in the agency’s fee schedule are not billable by Licensed Midwives. By law, a
Licensed Midwife may obtain and administer only certain medications. Drugs listed as not
billable by a Licensed Midwife must be obtained at a pharmacy with a physician’s order. (See
EPA criteria for drugs not billable by Licensed Midwives).

How are newborn assessments billed?

Home birth setting

To bill for a newborn assessment completed at the time of the home birth, providers must bill
using CPT code 99461. Reimbursement is limited to one per newborn. Do not bill CPT code
99461 if the baby is born in a hospital. Bill on a separate claim form and enter a B in field 19 of
the form for baby under mother’s Client ID.

Birthing center births

To bill for a newborn assessment completed at the time of a birthing center birth for a baby that
is admitted and discharged on the same day, use CPT code 99460. For a baby that is born in a
birthing center, when a newborn assessment is completed and the baby is transferred to a hospital
for care, bill with CPT code 99463.

How is the facility fee billed in birthing centers?

Note: The midwife may bill the agency for the facility fee or facility transfer fee
payment. The agency pays the midwife, who then reimburses the approved
birthing center. See Resources Available for a list of approved birthing centers.

Facility Fee –
When billing for the facility fee, use CPT code 59409 with modifiers SU and 59.
Only a facility licensed as a childbirth center by DOH and approved by the agency is eligible for
a facility fee. Bill this fee only when the baby is born in the facility. The facility fee includes all
room charges for mother and baby, equipment, supplies, anesthesia administration, and pain
medication. The facility fee does not include other drugs, professional services, newborn hearing
screens, lab charges, ultrasounds, other x-rays, blood draws, or injections.

Facility Transfer Fee –
The facility transfer fee may be billed when the mother is transferred in
active labor to a hospital for delivery there. Use CPT code S4005 when billing for the facility
transfer fee.

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Note: Payments to midwives for facility use are limited to only those birthing centers that have been approved by the agency. When modifier SU is attached to the delivery code, it is used to report the use of the provider’s facility or equipment only. The name of the birthing center must be entered in field 32 on the CMS-1500 claim form

What additional documentation must be kept in
the client’s record?

Prenatal care records

 Initial general (Gen) history, physical examination, and prenatal lab tests
 Gynecological (Gyn) history, including obstetrical history, physical examination, and
standard lab tests. Ultrasound, if indicated
 Subsequent Gen/Gyn history, physical and lab tests
 Client’s weight, blood pressure, fetal heart tones, fundal height, and fetal position at
appropriate gestational age
 Consultation, referrals, and reason for transferring care, if necessary.
 Health education and counseling
 Consultation or actual evaluation by the consulting physician for any high-risk condition.
 Risk screening evaluation
Intrapartum/postpartum care records
 Labor, delivery, and postpartum periods
 Maternal, fetal, and newborn well-being, including monitoring of vital signs, procedures,
and lab tests
 Any consultation referrals and reason for transferring care, if necessary
 Initial pediatric care for newborn, including the name of the pediatric care provider, if
known
 Postpartum follow-up, including family planning
Informed consent materials
 Copy of informed consent, including all of the following:
 Scope of maternal and infant care
 Description of services provided, including newborn screening, prophylaxis eye
treatment, and screening for genetic heart defects
Parents may refuse – documentation must include a signed waiver for each service that is declined  Limitations of technology and equipment in the home birth setting  Authority to treat  Plan for physician consultation or referral  Emergency plan  Informed assumption of risks  Client responsibilities and requirements

https://www.hca.wa.gov/assets/billers-and-providers/plannedhomebirths_bi_01012016-03312016.pdf

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Resource Home Births

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