CurrentPremera BluecrossPolicy N/A

Billing and reimbursement for multiple births/multiple deliveries on professional claims

Defines how Premera and affiliated plans limit billing and reimburse multiple gestation deliveries submitted on professional (CMS-1500 / 837P) claims; applies to all Premera Blue Cross, Premera Blue Cross Blue Shield of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company and Premera Blue Cross HMO lines of business and products.

Policy Summary

PayerPremera Bluecross

PolicyBilling and reimbursement for multiple births/multiple deliveries on professional claims

Policy CodePolicy N/A

Change TypeClarified, Added, Revised

Effective DateN/A

Next Review DateN/A

Key ActionBill all multiple births on the same professional claim with each birth on a separate line, append Modifier 59 (or other appropriate modifier) to second and subsequent birth delivery-only codes when necessary, include a Z37.* outcome diagnosis at the claim level, and submit documentation when Modifier 22 is used to support additional reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added clarifying statement that failure to bill each birth on the same claim with separate line items may result in denial of reimbursement.

Expanded Maternity Complications/High-Risk Pregnancies section detailing appropriate use of modifier 22 and documentation requirements to support additional reimbursement.

Revised guidance on correct usage of modifier 59 and correct diagnosis code usage for the outcome of delivery of multiple births.

All births on same claimRequired billing practice

Modifier 59 for 2+ birthsModifier requirement

Modifier 22 allowed

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When Additional Reimbursement or Adjustments Are Allowed

When additional reimbursement allowed for multiple deliveries

Conditions under which separate line items or additional payment/adjustment may be allowed.

ALL of the following

All multiple births must be billed on the same professional claim with each birth on a separate line.
Second and subsequent births must be appended with an appropriate modifier (e.g., Modifier 59) when necessary to indicate a separate and distinct birth from the first.
A diagnosis code indicating the outcome of delivery for multiple births (Z37.*) must be present at the claim level.

When modifier 22 may be appended

Criteria for increased procedural services reimbursement

ANY of the following

Maternity complications that necessitate additional work greater than typically required (examples include gestational diabetes affecting delivery, placenta previa/acceta, maternal sepsis, severe hypertension/preeclampsia including HELLP, cesarean delivery of multiples when billed by a global cesarean code, or single fetus delivery requiring substantial additional work).
Documentation (medical records, chart notes, operative reports) must clearly detail substantial extra work and specific complication to support modifier 22.
A diagnosis code reflecting the related maternity complication or increased delivery services must be included on the claim.

Relevant CPT and ICD-10 Codes

Global Maternity Care CodesCPT

59400	Routine obstetric care including antepartum care, vaginal delivery and postpartum care
59510	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
59610	Routine obstetric care including antepartum care, vaginal delivery and postpartum care after previous cesarean delivery
59618	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery

Delivery and Post-Partum Care CodesCPT

59410	Vaginal delivery only including postpartum care
59515	Cesarean delivery only including postpartum care
59614	Vaginal delivery only after previous cesarean delivery including postpartum care
59622	Cesarean delivery only following attempted vaginal delivery after previous cesarean delivery including postpartum

Delivery Only CodesCPT

59409	Vaginal delivery only
59514	Cesarean delivery only
59612	Vaginal delivery only after previous cesarean delivery
59620	Cesarean delivery only following attempted vaginal delivery after previous cesarean delivery

Antepartum and Postpartum Visit CodesCPT

59425	Antepartum care only; 4-6 visits
59426	Antepartum care only; 7 or more visits
59430	Postpartum care only (separate procedure)

Multiple Birth Outcome Diagnosis CodesICD-10

Z37.2	Twins, both liveborn
Z37.3	Twins, one liveborn and one stillborn
Z37.4	Twins, both stillborn
Z37.50	Multiple births, unspecified, all liveborn
Z37.51	Triplets, all liveborn
Z37.52	Quadruplets, all liveborn
Z37.53	Quintuplets, all liveborn
Z37.54	Sextuplets, all liveborn
Z37.59	Other multiple births, all liveborn
Z37.60	Multiple births, unspecified, some liveborn

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Billing, Documentation, and Denial Risks

Billing Rule

Claim line submission for multiple births

Bill all multiple births on the same professional claim with each birth on a separate line. Append Modifier 59 (or other appropriate modifier) to second and subsequent delivery-only codes when necessary to indicate a separate and distinct procedure. Include a multiple-birth outcome diagnosis (Z37.*) at the claim level and any other relevant complication diagnoses.

Affected CPT delivery code sets include: Global Maternity Care (e.g., 59400, 59510, 59610, 59618); Delivery and Post-Partum Care (e.g., 59410, 59515, 59614, 59622); and Delivery Only codes (e.g., 59409, 59514, 59612, 59620).
Diagnosis requirement: include an appropriate Z37.* code from the Multiple Birth Outcome Diagnosis list to indicate outcome of delivery.
Modifier guidance: Modifier 59 must be appended to second and subsequent newborn delivery-only codes when necessary to distinguish separate and distinct multiple deliveries.

Clinical and Administrative Context

This policy defines how Premera and affiliated plans limit billing and reimbursement for multiple gestation deliveries submitted on professional claims (CMS-1500 / 837P). It applies to all Premera Blue Cross, Premera Blue Cross Blue Shield of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company and Premera Blue Cross HMO lines of business and products, and follows ACOG coding guidance for vaginal, cesarean, or combined deliveries. Policy owner: Payment Integrity Oversight Committee; for questions contact the Payment Integrity Department.

All multiple births must be billed on the same professional claim with each birth reported on a separate line. The second and subsequent birth(s) must be appended with an appropriate modifier (for example, Modifier 59) when necessary to indicate a separate and distinct birth from the first. A diagnosis code indicating the outcome of delivery for multiple births (Z37.*) is required and must be present at the claim level. Failure to bill each birth on the same claim with separate line items may result in denial of reimbursement.

For cesarean deliveries, bill either a global maternity care cesarean code, a delivery and postpartum cesarean code, or a cesarean delivery-only code. No additional allowance will be made for subsequent newborns delivered via the same incision, unless distinct separate procedural services are documented and appropriately modified (e.g., Modifier 59 for second and subsequent delivery-only codes when required).

When maternity complications or high-risk conditions result in substantially greater work than typically required, Modifier 22 (Increased Procedural Services) may be appended to the delivery code. Documentation — medical records, chart notes, or operative reports — must clearly describe the substantial extra work and the specific complication (examples include gestational diabetes affecting delivery, placenta previa/accreta, maternal sepsis, severe hypertension/preeclampsia including HELLP, or cesarean delivery of multiples billed by a global cesarean code). Submitted records will be reviewed to determine appropriateness of additional reimbursement.

Violations of this policy may result in increased auditing and monitoring, contractual penalties, or termination unless an exception is specified by a provider or employer group contract.

Defined Terms

Definitions

Modifier 59Used to indicate a distinct procedural service when the second and subsequent birth(s) are separate and distinct from the first/initial birth. Must be appended to second and subsequent delivery-only codes when necessary to distinguish separate and distinct multiple deliveries.

Modifier 22Increased Procedural Services — may be appended when maternity complications necessitate additional work greater than typically required; must be supported by documentation (medical records, chart notes, operative reports) that clearly describe substantial extra work and the specific complication.

Policy Changes

2026-03-12clarifiedLatest

Added clarifying statement to the policy that failure to bill all multiple births on the same claim with each birth on a separate line may result in denial of reimbursement.

2024-04-11added

Expanded the Maternity Complications/High-Risk Pregnancies section with guidance on appropriate use of modifier 22 and documentation requirements to support additional reimbursement.

2024-04-11