CurrentAnthemPolicy G-06044

Multiple Delivery Services, Reimbursement Policy

Defines Anthem Medicaid Ohio reimbursement rules for billing multiple births (same-delivery and combined-delivery methods) including applicable modifiers and payment limits; applies to providers submitting claims to Anthem Ohio Medicaid Managed Care.

Policy Summary

PayerAnthem

PolicyMultiple Delivery Services, Reimbursement Policy

Policy CodePolicy G-06044

Change TypeReview — no material changes

Effective Date07/17/2024

Next Review DateN/A

Key ActionServices must meet authorization and medical necessity guidelines and be billed using standard CPT/HCPCS/revenue codes.

SourceLink

POLICY UPDATE CHANGES

Review approved and effective: no changes.

07/17/2024policy effective / last approval date

G-06044policy identifier

3rdmaximum paid delivery (no additional payment after)

Billing and Payment Criteria

Billing and payment criteria for multiple births

Anthem allows reimbursement for multiple births under the following billing and payment rules:

Reimbursement allowed for multiple births using same-delivery or combined-delivery methods unless provider, state, federal, or CMS contracts or requirements indicate otherwise.

From policy statement.

Same-delivery method

Vaginal or cesarean deliveries performed using the same delivery method should be billed with modifier 59.
Multiple procedure guidelines will apply.

Combined-delivery method

Vaginal deliveries in multiple births should be billed with modifier 51.
Multiple procedure guidelines will apply.

Policy Summary

PayerAnthem

PolicyMultiple Delivery Services, Reimbursement Policy

Policy CodePolicy G-06044

Change TypeReview — no material changes

Effective Date07/17/2024

Next Review DateN/A

Key ActionServices must meet authorization and medical necessity guidelines and be billed using standard CPT/HCPCS/revenue codes.

SourceLink

On This Page

Modifiers, Codes, and Payment Limits

Modifier guidance for multiple deliveriesModifierCovered

modifier 59	Use for vaginal or cesarean deliveries in multiple births when same-delivery method is used
modifier 51	Use for vaginal deliveries in multiple births when combined-delivery method is used
modifier 22	Use for cesarean deliveries in multiple births when combined-delivery method is used (multiple procedure guidelines will not apply)

Maximum paid deliveries

Maximum paid deliveriesNo additional payment after the third delivery of a multiple birth.

Effective date07/17/2024.

Policy identifierG-06044 (Anthem Ohio Medicaid).

Billing, Authorization, and Documentation Requirements

Documentation Required

Billing and authorization requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence. Follow proper billing and submission guidelines and use industry-standard CPT/HCPCS/revenue codes that are fully supported in the medical record; failure to follow coding/billing guidelines may result in claim rejection, denial, or recovery/recoupment of payment.

Obtain prior authorization when required and document medical necessity per the member's benefit plan and state requirements.
Use Current Procedure Terminology (CPT), HCPCS, and/or revenue codes on all claim submissions and support billed services in the medical record or office notes.
Ensure billing follows any applicable provider, state, federal, or CMS contract mandates that may supersede this policy.

Definitions: Same and Combined Delivery Methods

Same delivery method

DefinitionSame delivery method: Vaginal or cesarean deliveries in multiple births performed using the same delivery method should be billed with modifier 59.

Payment guidelineMultiple procedure guidelines will apply to same-delivery method billing.

Coding contextApplies to vaginal and cesarean deliveries when all deliveries use the same method.

Combined delivery method

DefinitionCombined delivery method: When deliveries in a multiple birth use mixed methods, bill vaginal deliveries with modifier 51 and cesarean deliveries with modifier 22.

Vaginal deliveriesBill with modifier 51; multiple procedure guidelines will apply.

Cesarean deliveriesBill with modifier 22; multiple procedure guidelines will not apply.