CurrentUnitedHealthcarePolicy 2023R7126B

Reimbursement Policy CMS-1500 and UB-04 — Early Elective Deliveries (NJFC Medicaid)

Defines UnitedHealthcare Community Plan / New Jersey FamilyCare Medicaid reimbursement requirements and denial rules for early elective deliveries and related labor and delivery claims billed on CMS-1500 or UB-04 forms; applies to all providers billing NJFC Medicaid.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS-1500 and UB-04 — Early Elective Deliveries (NJFC Medicaid)

Policy CodePolicy 2023R7126B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport ICD-10-CM gestation week code (Z3A) on all labor and delivery claims; claims without a gestation week code will be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Z3Agestation week required or denied

39 wksEED denial threshold

59409/12/14/59514/59612/20Professional CPTs checked

AllowedDoula billing allowed

NJFC Medicaid Labor & Delivery Reimbursement Criteria

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NJFC Medicaid labor and delivery reimbursement criteria

Reimbursement for labor and delivery services under New Jersey FamilyCare (NJFC) Medicaid is subject to the following required documentation, gestational-age thresholds, and medical‑necessity rules. Failure to meet these criteria will result in claim denial.

All labor and delivery claims must include an ICD-10-CM week-of-gestation diagnosis code from category Z3A. Claims submitted without a gestation week code shall be denied.

Claims reporting a week-of-gestation code of less than 39 weeks must document medical necessity as specified below or will be denied.

Exceptions to medical‑necessity requirement for <39 weeks

Inpatient facility C-section or medically necessary induction reported with condition code 81: a high‑risk diagnosis is not required for the claim to be considered for reimbursement.
Professional claim for delivery prior to 39 weeks with SC modifier appended: a high‑risk diagnosis is not required for the claim to be considered for reimbursement.

Professional procedure codes requiring additional diagnosis when gestation <39 weeks

If a professional claim reports one of the procedure codes 59409, 59412, 59414, 59514, 59612, or 59620 AND the week‑of‑gestation code is less than 39 weeks, the claim must also include one of the following medically necessary ICD‑10‑CM diagnosis categories: O10, O11, O12, O13, O14, O15, O16, O24, O30, O31, O33, O35, O36, O42, O43, O44, O45, O71, or R03. Claims failing to include one of these diagnosis codes will be denied.

Spontaneous vaginal deliveries <39 weeks: Spontaneous vaginal deliveries less than 39 weeks should be coded using 10E0XZZ or another appropriate code in the 10D0 series to be considered for reimbursement.

Early Elective Delivery (EED) denial rule: Scheduled cesarean sections or medical inductions performed prior to 39 weeks of gestation without medical indication (Early Elective Deliveries) are not reimbursable under NJFC Medicaid.

Doula billing: Doula providers are permitted by NJ state law to be present at delivery and may bill CPTs 59409 and 59514; such claims shall be allowed reimbursement when otherwise meeting documentation requirements.

Operational note

Codes, Gestational Age Cutoff, and Coding Requirements

Covered CPT/Procedure CodesCPTCovered

59409	Vaginal delivery or doula billing (as listed)
59412	Delivery procedure code requiring gestation/week verification
59414	Delivery procedure code requiring gestation/week verification
59514	Delivery procedure code requiring gestation/week verification
59612	Delivery procedure code requiring gestation/week verification
59620	Delivery procedure code requiring gestation/week verification
Z3A.*	ICD-10-CM gestation week codes (required)

Spontaneous vaginal delivery procedure codes (reimbursement consideration)CPTCovered

10E0XZZ	Spontaneous vaginal delivery (code to be used for consideration when <39 weeks)
10D07Z3	Example 10D0-series delivery code (used for spontaneous vaginal deliveries <39 weeks)
10D07Z4	Example 10D0-series delivery code (used for spontaneous vaginal deliveries <39 weeks)
10D07Z5	Example 10D0-series delivery code (used for spontaneous vaginal deliveries <39 weeks)
10D07Z6	Example 10D0-series delivery code (used for spontaneous vaginal deliveries <39 weeks)
10D07Z7	Example 10D0-series delivery code (used for spontaneous vaginal deliveries <39 weeks)
10D07Z8	Example 10D0-series delivery code (used for spontaneous vaginal deliveries <39 weeks)

Gestational age cutoff — 39‑week threshold

Gestational age cutoffDeliveries before 39 weeks gestation that are non‑medically indicated (early elective deliveries) are not reimbursable; claims reporting a week of gestation <39 without an allowed medically necessary diagnosis will be denied.

Effective date referenceNJ state law prohibits reimbursement for non‑medically indicated EEDs with dates of service on or after January 1, 2021.

Claim denial triggerClaims submitted without an ICD‑10‑CM Z3A week‑of‑gestation code shall be denied payment.

Claim Submission, Documentation, and Denial Risk Guidance

Documentation Required

Report week-of-gestation (ICD-10-CM Z3A) on labor and delivery claims

Providers must report an ICD-10-CM diagnosis code indicating the week of gestation (ICD-10-CM category Z3A) on all labor and delivery claims. Claims submitted without a week-of-gestation diagnosis code will be denied. When reporting a week-of-gestation code of less than 39 weeks, include an appropriate medically necessary diagnosis code from the listed ICD-10-CM categories (e.g., O10–O16, O24, O30–O36, O42–O45, O71, R03) to avoid denial.

Required: ICD-10-CM Z3A week-of-gestation codes on labor and delivery claims
Claims without Z3A week-of-gestation code will be denied
If Z3A indicates <39 weeks, include an appropriate medically necessary diagnosis code from the specified ICD-10-CM categories

Denial Risk

Denial risk for non-medically indicated early elective deliveries (EEDs)

Non-medically indicated early elective deliveries (EEDs) — defined as scheduled cesarean sections or inductions performed prior to 39 weeks without medical indication — are not reimbursable. Providers should ensure scheduling follows ACOG guidance and state law; educational materials are recommended to inform patients of risks. Claims for EEDs with date of service on or after January 1, 2021, will not be reimbursed.

Definition: scheduled cesarean or induction prior to 39 weeks without medical indication
NJFC Medicaid will not reimburse professional, hospital, or clinic claims for non-medically indicated EEDs with DOS on/after 2021-01-01

Billing Rule

Condition code 81 / SC modifier exception for medically necessary early deliveries

Condition code 81 may be used to indicate preterm delivery when reporting C-sections or medically necessary inductions <39 weeks; when condition code 81 is present for these medically necessary deliveries, a separate high‑risk diagnosis is not required for consideration of reimbursement. For professional claims, the SC modifier similarly indicates medically necessary early delivery and obviates the need for a high‑risk diagnosis.

Facility claims: C‑section or medically necessary induction <39 weeks reported with condition code 81 — high‑risk diagnosis not required
Professional claims: delivery prior to 39 weeks with SC modifier — high‑risk diagnosis not required

Key Definitions

Early Elective Delivery — definition

DefinitionEarly Elective Delivery (EED): scheduled cesarean sections or medical inductions performed prior to 39 weeks of gestation without medical indication; not justified solely by maternal request, pain management availability, or scheduling issues.

Examples of procedures considered EEDScheduled cesarean section or planned medical induction performed before 39 weeks when no medical indication is documented.

Guidance resourcesACOG Patient Safety Checklist for Planned Caesarean Deliveries and ACOG Patient Safety Checklist for Scheduling Induction of Labor may be used to assess appropriateness of scheduling.