Billing Anthem for anesthesia services administered during labor and delivery requires physicians to follow specialized guidelines, otherwise the claims will likely be denied.
Gestational Age at Birth
The first guideline was announced by Anthem last August for several states, including Indiana. Beginning with dates of service November 1, 2018, and following, all professional delivery claims (59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620 and 59622) require an ICD-10 Z3A code indicating the newborn’s gestational age at the time of delivery. If the code is not found on the claim, or if the code is included as Z3A.00 indicating “Weeks of gestation of pregnancy not specified,” the claim will be denied. The following reason will be given so providers can identify the denial and correct the claim: “Delivery diagnoses incomplete without report of pregnancy weeks of gestation. You may resubmit the corrected claim with the appropriate ICD-10 code for payment.”
While the policy doesn’t specifically mention anesthesia claims for delivery, CIPROMS also has seen denials for anesthesia delivery claims if the newborn’s gestational age is not on the claim or is listed as unspecified. As indicated in the denial reason, the claim can be resubmitted with the necessary information, but including the gestational age on the claim with the first submission will help you avoid unnecessary denials and follow-up.
Labor and Delivery over 300 Minutes
The other policy applies only to Anthem’s Medicaid plans (specifically Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect in Indiana) and Medicare Advantage plans. While the policy has been in place for a while, it continues to create extra work on the back end of claims submission.
For professional neuraxial epidural anesthesia services provided in conjunction with labor and delivery over 300 minutes, providers must submit additional documentation upon dispute for consideration of reimbursement. The documentation needs to explain the lengthy delivery by offering a timeline of the placement of the epidural and other events throughout the delivery as recorded in the delivery summary. Reimbursement for providers other than the delivering physician is based on the allowance calculation plus the inclusion of catheter insertion and anesthesia administration.
In addition to labor and delivery anesthesia claims, CIPROMS also has seen other cases that exceed 300 minutes (namely cardiac cases) where additional documentation was requested explaining the length of service.
While Anthem has given no indication that this documentation should be sent preemptively for anesthesia cases over 300 minutes (only “upon dispute”), it is important to make sure the documentation is available and the billing staff knows where to find it when Anthem requests additional documentation in order to consider reimbursement.
For more information, review the following documents from Anthem:
- Anthem Announcement: Gestational age required for professional delivery claims effective November 1, 2018
- Anthem Blue Cross and Blue Shield Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Reimbursement Policy: Professional Anesthesia Services
- Anthem Blue Cross Medicare Advantage Reimbursement Policy: Professional Anesthesia Services
- Anthem Blue Cross and Blue Shield Professional Reimbursement Policy: Anesthesia Services
- Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy: Routine Obstetric Services
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