Effective Date: January 1, 2021

Last Updated: March 6, 2022

Purpose:

This policy provides reimbursement guidelines for non-medically indicated early elective deliveries for both professional and facility claims.

Scope:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

Early Elective Delivery: Scheduled cesarean sections or medical inductions performed prior to 39 weeks of gestation.

Policy:

In accordance with N.J.S.A.§30:4D-9.2 and the New Jersey Medicaid Managed Care Contract, Horizon NJ Health will deny early elective deliveries that are not medically indicated in accordance with established standards of clinical care as provided by the American College of Obstetricians and Gynecologists (ACOG).

For dates of service beginning on January 1, 2021 and thereafter, all claims for delivery services must include the gestational age diagnosis code (Z3A.XX). Horizon NJ Health will deny any delivery service claim that does not include such diagnosis code.

In addition, for dates of service beginning on January 1, 2021 and thereafter, delivery claims submitted with a gestational age diagnosis code of less than 39 weeks must also include one or more additional diagnosis code(s) from one of the following diagnosis codes to demonstrate that the early delivery is medically indicated:

A diagnosis code from one of the following series coded to the appropriate character:

• O10
• O11
• O12
• O13
• O14
• O15
• O16
• O24
• O30
• O31
• O32
• O33
• O35
• O36
• O41
• O42
• O43
• O44
• O45
• O64
• O68
• O69
• O71
• O76
• or O80*

OR

One of these specific diagnosis codes:

• O26.42
• O26.43
• O26.612
• O26.613
• O34.212
• O34.29
• O34.519
• O34.533
• O46.002
• O46.003
• O46.012
• O46.013
• O46.022
• O46.023
• O46.092
• O46.093
• O46.8X2
• O46.8X3
• O46.92
• O46.93
• O60.10
• O60.12
• O60.13
• O60.14
• O60.20
• O60.23
• O62.3
• O66.6
• O67.0
• O67.8
• O67.9
• O75.0
• O75.1
• O77.1
• O77.8
• O77.9
• O98.112
• O98.113
• O98.12
• O98.13
• O98.212
• O98.213
• O98.22
• O98.23
• O98.712
• O98.713
• O98.72
• O98.73
• O99.322
• O99.323
• O99.324
• O99.325
• or R03.0

*O80.0 can be used when the gestational age is >/= 37 weeks

Procedure:

Horizon NJ Health will not consider for reimbursement a delivery claim without a gestational week diagnosis code (Z3A.XX).

Horizon NJ Health will not consider for reimbursement a delivery claim with a gestational age of less than 39 weeks that does not also include a secondary diagnosis code to support the need for an early delivery.

Medical records for each delivery service must include sufficient documentation to support all diagnosis codes and demonstrate the medical necessity of any early elective delivery.

Resources:

N.J.S.A. § 30:4D-9.2, “Medicaid to not provide coverage for certain early elective deliveries.”

New Jersey Medicaid Managed Care Contract, Section 4.2.3 “Women’s Health Services,” Section E “Non-medically indicated early elective deliveries.”

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.