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The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

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Sample Billing Scenarios for a Homebirth Midwife

Practice Variation in Cesarean Rates: Not Due to Maternal Complications
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients.  This analysis shows that:

    Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
    Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
    Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.

Tips for Choosing a Care Provider - great overview! from Henci Goer

Overview

Timing the Filing Of Claims

Prenatal Care

Birth Services

Postpartum Care for the Mother

Newborn Care

Equipment

Doula Work

Billing for a Transport

Overview

General Disclaimer

You are welcome to use the information herein to help figure out how to bill for services you provide your clients.
You do so at your own risk - filing insurance claims is serious business, and filing fraudulent claims is a criminal offense, with high penalties, including time spent in jail and high monetary penalties  If you are not sure that your billing is appropriate and legal, you must seek appropriate advice from a lawyer or an insurance billing service.
Good, sensible insurance billing can really boost your income without creating an undue burden on your clients.  I just ask that when you start making more than enough to support yourself, you make sure to support the midwifery organizations that allow you to continue to practice legally and thus to bill insurance.

General Information

Filing an insurance claim is like telling a story, except that you're limited to a very small vocabulary, and you have to tell the story in just the right format.  The first part of the story is the Diagnosis, i.e. what was the medical reason for providing these services.  After all, you weren't just having a tea party, right? because health insurance doesn't cover tea parties.  Your client was probably pregnant, in labor or postpartum, and there may have been some complications that required additional services.  So, after you've described the reasons for providing care, then you tell the part of the story about the exact care you provided - was it an office visit or a home visit, or were you "performing a procedure", such as attending a birth?  Or maybe you were providing specialty supplies such as a birthing tub, pitocin or oxygen?

Completing the HCFA Form

Just as there is a specialized vocabulary for filing insurance claims, so there is also a specialized format - the HCFA form.  These are pre-printed in red ink so that they can be printed on by computers in black ink that can be scanned by other computers more easily.  Here are the guidelines for Completion of the HCFA-1500 Claim Form and here are some of my own notes: HCFA Boxes - Step by Step.

Diagnosis Item #

The language of Diagnosis Codes is very specific, and it's hard to learn the language without a good dictionary.  Each of the categories of codes has a different number of codes, and if a code requires five digits, you must use five digits.  Sometimes the extra digits for maternity codes describe whether the condition or complication occurred prenatally, during labor, or postpartum.  You can either purchase a coding book or coding software.  I'm very happy with my Ingenix Encoder Pro software, which came with an intro. book.

Now, one of the weird things about diagnosis codes is that they don't appear on the same line as the procedure performed.  Instead, they appear in their own little section, where each one is assigned an ordinal number, i.e. 1, 2, 3, 4.  This isn't just to drive you nuts - it's to minimize the errors that can occur with the complicated diagnosis codes.  You only have to specify each diagnosis code once per set of claims, and then after that, every time you refer to that diagnosis code, you just say "The first one" or "the second one".  Generally, you want to put the more serious diagnoses first.  You're limited to 4 diagnosis codes per claim item, so if you have more than 4 for a single claim item, just use the 4 most serious diagnoses.  On this web page, I include a description of the diagnosis, but the insurance company doesn't need to see that, because they use the same dictionary to translate the diagnosis codes into descriptions.

Here's more information about Diagnosis Codes, i.e. ICD-9, including my ICD-9 Notes.

Date(s) Of Service

When billing the routine global fee, use the Date of Birth here.  When billing just for prenatal care, you can bill the range of dates, and then put the number of appointments as "Days or Units".  Prolonged codes should be totaled for each 24-hour period.  Some billing services put dates in both columns, even when they're the same, but the guidelines say you can leave the second column blank if they're the same.

Place of Service - Here are the most common ones for maternity services:  For more information, see HCFA Place of Service Codes

CPT-4 # - Procedures, Services, Or Supplies

Again, this is a specialized language with a specialized vocabulary.  You need to buy a good "dictionary" in order to use this language well, although you could get by with the examples here for the most common situations. Here are some notes, though, and here are some Evaluation & Management Code Definitions.

MODIFIERS

NOTE - I'm no longer using 59400 since it's really an inappropriate way to describe the comprehensive care provided by a homebirth midwife.  Instead, I'm filing claims for all the individual services I provide and using 59409 for the one hour around the birth itself.  True midwifery care is very different from "routine OB" care; our appointments tend to be an  hour long or longer as we include nutritional and emotional review along with the basic assessments.  So I bill for individual appointments as I go along.

Modifiers are very important in billing for homebirth services, because so much of what we do is IN ADDITION to the basic services of 59400 and often on the same day..  Any claims that you file for E&M services provided on the same day as 59400 but beyond the scope of 59400 should have the -25 modifier.  This modifier is for E&M service that is a significant, separately identifiable service from 59400.  This applies to the labor monitoring and postpartum recovery care that would normally be provided by nurses, pediatricians, or lactation consultants in the hospital.  Modifiers get applied like this:

99354-25

Key modifiers:

Modifier -25, "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service,"
Modifier -21, "Prolonged Evaluation and Management Services," when an E/M service takes more time than is usually required for the highest level of service within a given E/M category; some sources say this code is becoming obsolete or not generally considered
Modifier -24 Unrelated evaluation and management service by the same physician during postoperative period: If the physician needs to indicate that an evaluation and management service was performed during a postoperative period for a reason or reasons unrelated to the original problem, the circumstance shall be reported by adding the modifier -24.  This would apply to lactation consulting provided during the postpartum period, as they are outside the scope of 59400.
Modifier -53 Discontinued procedure: If the physician elects to terminate a surgical or diagnostic procedure because of extenuating circumstances or circumstances that threaten the well being of the patient, the decision to terminate or discontinue the procedure shall be reported by adding modifier -53 to the code of the discontinued procedure. Modifier -53 shall not be used to report the elective cancellation of a procedure before the patient’s anesthesia induction or surgical preparation in the operating suite, or both.  This MIGHT be most suitable for a transport.
Modifier -76, "Repeat Procedure by Same Physician," when a procedure or service was repeated subsequent to the original procedure or service.  For example, when you make multiple home visits during early labor or for the birth and a postpartum followup visit the same evening as the birth. to the original procedure or service.  For example, when you make multiple home visits during early labor or for the birth and a postpartum followup visit the same evening as the birth.
Modifier -32, "Mandated Services," Services related to mandated consultation and/or related services, (e.g. PRO, third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier -32 to the base procedure.  I don't know if this is an appropriate code to use for postpartum care within 48 hours, often mandated to be covered by insurance.
Modifer -52, "Reduced Services" for when you transport into the hospital after starting labor at home.
Modifer -62, "Two Surgeons", when two surgeons work together as primary surgeons performing distinct parts of a procedure.  For example, if you're doing two-person Neonatal Resuscitation, you might use -62.

EXTRA CPT-4 Codes

These codes can be combined with other services or procedures.  Note that some of them don't make sense, i.e. combining "Home Services" with a "Home Visit", but you might try it anyway.  Some insurance companies will deny charges for the extra claim for working outside office hours for OB care, since they figure it comes with the territory, but, again, why not claim it?  Some insurance companies do honor this, even for 59400, and they should certainly honor it for postpartum visits on Saturdays, Sundays and holidays when done within 48 hours of the birth, since these visits cannot be postponed.  And if you're making an emergency visit for a screaming baby who won't latch on to an engorged breast at 4 in the morning, then by all means, claim 99052!

99052, Services requested between 10:00 PM and 8:00 AM in addition to basic service,$58.54
99054, Services requested on Sundays and holidays in addition to basic service,$58.54
99050, Services requested after office hours in addition to basic service ,$29.60

99056, Home Services

Charges

There are benchmark fees assigned to each CPT-4 Procedure, Service or Supply.  These benchmark fees are multiplied by geographic multipliers to determine the Usual, Customary and Reasonable charge for that item in your area.  And then each insurance company does whatever they want with the number, such as cut it in half and call it a "negotiated fee".  Ha, ha.  I'm amazed at the range of UCR fees from different companies!  The charges listed here are benchmark fees from a few years ago, multiplied by 2.  Here in Silicon Valley, where "starter homes" cost half a million, the multiplier is more like 3.  These numbers are primarily useful in that they give you a sense of the relative value of different procedures.

Days or Units

This number will generally be 1, unless you're billing for prolonged services codes where you bill each half hour as 1 unit of service.  Or if you're billing prenatal care separately from the global fee, then you would use this to describe how many routine prenatal appointments you had.

Timing the Filing Of Claims

Experience has taught me that the timing of the filing of claims can affect how well they are paid.  In particular, I've noticed that submitting all of the claims at one time tends to raise red flags at the large amount and seems to make it more likely that the claim will be bumped up to a higher level of review.  So I now try to keep claim totals to under $1000 when possible.  And it makes sense to submit prenatal claims as soon as possible; they're more likely to get paid before the birth claim is received, especially if you use a global code.  (One exception is that I sometimes hold the home visit claim until after the birth, since it is only justified in cases where the midwife needs to inspect the home in preparation for a homebirth.)  So, here are some suggestions for the timing of claims for a typical cycle of care:

[Please note that I changed this in 2011.  Honestly, I've pretty much just started filing all the claims as the services are provided, although I will hold the birth claim (59409) until after the larger claims for labor monitoring/management and postpartum recovery and newborn care are paid. ]

Initial visit and additional prenatal visits - file these as soon as they occur.
Followup Postpartum Care within 48 Hours - These are the home visits to check on the mom in the two days right after the birth; if I've got time, I'll file these as soon as they occur.  But if I don't get around to it right away, I'll file the other postpartum followup claims first, since they have a slightly weaker legal support and depend on the generous terms of the family's policy.  These claims within 48 hours are required to be covered in California by the "No Drive-through Deliveries" laws.
Followup Newborn Care within 48 Hours - These are the home visits to check on the baby in the two days right after the birth; if I've got time, I'll file these as soon as they occur.  But if I don't get around to it right away, I'll file the other newborn followup claims first, since they have a slightly weaker legal support and depend on the generous terms of the family's policy.  These claims within 48 hours are required to be covered in California by the "No Drive-through Deliveries" laws.
Followup Postpartum Care after 2 Days - I do home visits at 5 and 10 days, depending on what's going on with the mom's well-being and with breastfeeding.  If I've already filed the claims for care within 48 hours, I'll hold these for a couple of weeks after that.  But if I haven't filed those claims yet, I'll file these right away and hold the other claims since these have a slightly weaker legal support and depend on the generous terms of the family's policy.
Followup Newborn Care after 2 Days - I do home visits at 5 and 10 days, depending on what's going on with the baby's well-being and with breastfeeding.  If I've already filed the claims for care within 48 hours, I'll hold these for a couple of weeks after that.  But if I haven't filed those claims yet, I'll file these right away and hold the other claims since these have a slightly weaker legal support and depend on the generous terms of the family's policy.
Claims for Labor Monitoring and Immediate Postpartum Care - These are the claims for all the additional time you were there with the mom before she got close to birthing, and in the hours afterwards, when she's unstable and needing frequent assessments.  I will often wait until all the other claims have settled before submitting this claim because it's often for a large amount, and it's one of the easiest to justify; in California, coverage for this care is mandated by the "No Drive through Deliveries" laws, and anyone can see that it would be abandonment to leave a mom just a half hour after she has given birth, as obstetricians do in the hospital, as described by 59400.  This fee is directly comparable to the hospital charges since it's equivalent to the equipment and nursing labor monitoring and postpartum recovery and maternity care provided by hospital staff.  This claim also highlights the fact that the birth occurred at home, which can raise additional flags that previous claims might not have, and it's just easier to deal with it when you've got the law firmly on your side.
Claims for Newborn Care - These are the claims for all the additional time you were there after the birth, caring for the unstable newborn needing frequent assessments.  I will often wait until all the other newborn claims have settled before submitting this claim because it's often for a large amount, and it's one of the easiest to justify; in California, coverage for this care is mandated by the "No Drive through Deliveries" laws, and anyone can see that it would be abandonment to leave a newborn who was just born.  And, despite various misconceptions on the part of insurance companies, this care is OBVIOUSLY not covered by 59400, which is a maternity code.  NO, maternity codes do not apply to newborns, and especially not the males.  :-).  This fee is directly comparable to the hospital charges since it's equivalent to the equipment and newborn nursing care provided by hospital staff.  This claim also highlights the fact that the birth occurred at home, which can raise additional flags that previous claims might not have, and it's just easier to deal with it when you've got the law firmly on your side.
The birth claim - 59409 - I will sometimes wait and file this as one of the last claims, since it can trigger problems with getting other claims filed. Sometimes I'll include the claims for the surgical tray and/or birthing tub along with the birth claim.

Prenatal Home Visit - I'll often file this last, just because it's a smaller amount and doesn't fit conveniently into the other bunches.

So, for a birth that happens on Jan. 1, I will have previously filed the claims for prenatal care, excluding the home visit. I might file the birth claim within a few days after the birth and then submit the other claims according to this timetable:
Jan. 15    Home visits on Days 5 and 10 for mother.  Separate claims for home visits for baby on Days 5 and 10.
Jan. 31    Home visits on Days 1 and 2 for mother.  Separate claims for home visits for baby on Days 1 and 2.
Feb. 15    Labor monitoring and immediate postpartum care for mother. Separate claims for immediate newborn care.
Feb. 28    File any remaining claims, such as prenatal home visit and assistant services.

I know it seems counterintuitive to stagger the filing of the claims, but I have found that this reduces the holds on the larger claims and actually gets everything tidied up sooner.  And it really does reduce the insurance company's perception that everything's lumped in with the global fee.  It's also easier to file the handling of appeals when you deal with them in smaller sets of claims, where all the claims in that bunch are supported by the same reasoning.
 

Prenatal Care

Here's an easy starter claim - billing for the initial visit.  This is pretty easy to explain to the insurance company - the client is pregnant, and you're providing a comprehensive initial office visit for a new patient.  Let's just say that this is the client's first pregnancy, so the Diagnosis is V22.0 Normal First Pregnancy, but you might use any of these pregnancy codes for other situations:

V22.0 Normal First Pregnancy - only if no complications
V22.1 Other Normal Pregnancy - only if no complications
V23.0 Pregnancy with history of infertility
V23.3 Pregnancy with grand multiparity
V23.41 Supervision of pregnancy with history of pre-term labor
V23.49 Supervision of pregnancy with other poor obstetric history
659.53 Elderly primigravida, antepartum only
659.63 Elderly Multigravida, antepartum only

Here's what your claim looks like.  First, you specify the diagnosis:
Diagnosis Item #
ICD-9 Code
Description
1
V22.0
Normal First Pregnancy

Then, you specify the services provided:
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
11
99204
New Client (>3 yrs since last seen) comprehens. OV - 45 min
1
$199.16
1
MM DD YY
11
81002
Urine dipstick
1
$8.25
1

This paragraph pertains to midwives who have hour-long prenatal appointments, including nutrition and emotional support, along with education about general self-care and preparation for an unmedicated homebirth.
File claims for individual prenatal appointments as they occur.  Your client will almost always have some kind of discomfort that requires extra attention to rule out more serious complications and to help prevent future ones.  (I recommend Clinical Guidelines For Midwifery & Women's Health by Nell Tharpe to assist with billing as well as clinical guidelines. She offers a range of possible diagnostic codes for situations which require extra care.)
 
Diagnosis Item #
ICD-9 Code
Description
1
Complication Code Complication

Select the appropriate CPT code depending on how much time the appointment requires.  If it goes over 40 minutes, you may need to tack on 99354.
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
11
99213
Est,exp.prob-focused OV-15 min
 
1
Your Fee
1
MM DD YY
11
99214
Est,detailed OV-25 min
1
Your Fee
1
MM DD YY
11
99215
Est,comprehens./high OV-40min
1
Your Fee
2
MM DD YY
11
99354
Prolonged physician service in the office
1
Your Fee
1

 

This paragraph pertains to midwives who run their practices similarly to "routine OB care", with ten-minute prenatal appointments.
Ideally, your client has no complications and no reasons for any extra care during her pregnancy.  So all the prenatal appointments beyond the initial visit are bundled with the birth itself as part of the CPT-4 procedure "Global routine OB care", which we'll talk about when billing for the birth itself.  For a homebirth midwife, it's standard of care to do a home visit around 36 or 37 weeks to assess readiness for the birth, and this is extra care beyond 59400, so you can bill separately for it:  Now, here we get to the first little complicated part of billing for homebirth care.  There is no good way of describing why you're going to the woman's home.  If she were planning a hospital birth, you wouldn't go to her home just because she's pregnant.  So when an insurance company receives a claim for a home visit for a pregnant woman with no complications, they're not likely to pay it.  Unfortunately, the ICD-9 language just doesn't have a special word for "Homebirth", so you have to figure out what's going to work for you.  Sometimes I've just billed with the standard pregnancy diagnosis, and the visit has been covered, especially if it comes in with the birth claims and they can see that the baby was born at home.  But if you're filing it separately from the birth claims, you might want to provide some additional information.  The best way I can think of to do this is to use the Diagnosis Code - 659.83 - "Other specified indication for care or intervention related to labor and delivery, antepartum", which means that there's something unusual about this pregnancy that requires care beyond the standard OB care.  And, of course, you want your story to include this important detail, which you can specify on the HCFA form in Box 19 - Planning Homebirth.  (Please note that this is experimental.  Please let me know how this works for you!)
 
 
Diagnosis Item #
ICD-9 Code
Description
1
659.83
Other specified indication for care or intervention related to labor and delivery, antepartum
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
99350
Home visit for the eval & mgnt of an established pt Home visit to Assess Readiness
1
$259.72
1
MM DD YY
12
99056
Home Services Home visit to Assess Readiness
1
$29.60
1

Birth Services

Now we come to the fun part - billing for the birth itself.

Starting with reality, suppose there's some false labor, and you end up going to the home and leaving again before the baby is born.  This "episode of care" is technically antepartum care, so you want to be sure that your diagnosis reflects that fact.  Here's how you might bill for it:
 
 
Diagnosis Item #
ICD-9 Code
Description
1
644.13 Other threatened labor - antepartum condition not delivered

Note that other reasonable diagnosis codes might be:

661.43 Hypertonic incoordinate or prolonged uterine contractions - antepartum condition not delivered,
658.23   Delayed delivery ( > 24 hours to the onset of labor) after spontaneous or unspecified rupture of membranes- antepartum condition or complication
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
99350-25
Home visit for the eval & mgnt of an established pt - PRIMARY SERVICE
1
$259.72
1
MM DD YY
12
99354-25
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)
1
$370.00
1
MM DD YY
12
99355-25
2  units @ $180 - of Prolonged service in outpatient setting (each add'l half hour) 
1
$360.00
2
MM DD YY
12
59025
Fetal non-stress test.
1
$175.00
1

Now we come to the birth itself.  Here you finally get to bill for the "Global routine OB care".  Don't make the mistake of thinking that this is the same as "Global routine Homebirth Midwifery Care"!  I figure that "Global routine OB care" covers about 4 hours of care - average 10-15 minutes each for about 12 appointments, about 45 minutes at the birth itself, and about 15 minutes in stop-by postpartum visits during which the OB breezes in and out of the room, perhaps looking at the nurses' notes or asking the mom if there are any problems.  Now, seriously, have you ever had a client for whom you provided all the prenatal care, caught the baby and provided postpartum care for the mother and newborn in anything less than 20 hours, not counting travel time?  Personally, I spend an average of 40-60 hours with each of my clients.  Most insurance companies don't cover extended prenatal appointments for normal pregnancies, although some midwives get creative about billing for education, nutritional counseling, etc.  But they should be happy to pay for the time you spend providing services that would otherwise be provided by hospital staff for a hospital birth at hospital prices!

What I'm doing here is billing for the extra time that homebirth midwives spend at a birth - the many hours spent doing labor monitoring (in addition to the labor management that OBs do remotely), and the 3-6 hours or more that is spent providing postpartum nursing care (monitoring vital signs of mother and baby), breastfeeding assistance or lactation consulting, and remaining on the premises with your emergency equipment, prepared to handle any life-threatening emergencies that might arise for mother and baby within the first delicate six hours after birth.  I choose six hours because that's the time that most birth centers keep clients, and the minimum time that our local hospitals will even consider "allowing" a mom to leave the hospital after a straightforward birth.  Also, when I took an advanced two-day course on complications of the newborn period, the instructor (Tracy ???) was very clear that most serious complications show up within six hours.  So the newborn is safe to be left alone at six hours if no complications have been detected by then and there aren't any particular risk factors. The midwife standard of care is to be present from the time that active labor is established until the postpartum mother and newborn are stable and safe to be left alone.

Anyway, the time you spend during labor and the hours you spend postpartum are NOT included in 59400.  To avoid confusion, I no longer bill 59400 at all.  I bill the one hour around the time of birth as 59409 and then bill all the rest of the time explicitly.

So . . . how do you bill all the rest of the time?  Well, again, there aren't good codes to describe what midwives do at a homebirth, so this is where you learn to become good friends with the prolonged care codes, which are billed in half hour increments beyond the first hour.  I figure the first hour of my time at the birth gets included in 59409, and then everything after that is extra.  I'm still not sure whether it's better to break this time up into pre-birth and postpartum time.  I used to separate out the extra labor time from the extra postpartum time - I think this does a better job of "telling the story", and California state law requires health insurance companies to cover care provided within the 48 hours after birth, so I wanted to have that part of the claim separate, in case I had to write an appeals letter about it.  This is how I used to do it, but now I lump all the 99355 together.

Suppose you arrive at the home at midnight, and everything goes really well and baby is born at 5 am.  I would break it down as follows:

Midnight - 1 am   1 hour for 99350 - Home Visit - Needed as the companion code for 99354/99355.
1 am - 2 am        1 hour for 99354 - First hour of  "Prolonged service in outpatient setting"
2 am - 4 am        2 hours == 4 units of 99355 "Prolonged service in outpatient setting"
4 am - 5 am        Included in 59400
5 am - 11 am      6 hours == 12 units of 99355 "Prolonged service in outpatient setting"

It's cleaner to code all the prolonged time as a single claim of 16 units of 99355 "Prolonged service in outpatient setting", perhaps attaching a cover letter to explain the allocation of hours, which would also be a good basis for writing an appeals letter.  So, in this example, I'm combining the extra time spent doing labor monitoring and postpartum care.  In fact, some resources I've come across suggest that ALL the prolonged time should be billed as a lump, even if it was in separate chunks of time.  [Note that Don Self says that 99354/99355 may only be billed in addition to an E&M service that has a time factor associated with it (companion codes 99201 - 99233).]

So . . . that was all about the CPT codes describing the services you provided.  But how do you justify spending so many hours with the birthing woman?  After all, you're charging a lot for your time, so it makes sense to provide a good reason, right?  Well, obviously, you're there because she's at home, and you don't have a staff of nurses providing the care for you.  So . . . you can describe this as 659.81 "Other specified indication for care or intervention related to labor and delivery, delivered", w/"Planned Homebirth" as the narrative description in block 19 of the HCFA form.  This will help them to understand that they will NOT be receiving a hospital bill for time spent in Labor and Delivery, another 2 days in Maternity, and 2 days for the baby in the Nursery.  They'll be so grateful, they'll kiss your feet!

[NOTE - For years, I used "650 - Normal Birth" as the diagnosis for all my services at the birth.  And the insurance companies usually honored the 59400 claim for the birth itself, but they often denied all the extra charges.  After all, if there weren't any complications, why was I spending so much time with this woman - we were probably just having a tea party at 5 am, right?!?  And then I'd end up writing appeals letters, some of which were granted, but it's a drag.  And I noticed that for the births where there WERE complications, the extra charges were being allowed more easily.
So . . . as much as it goes against my grain to call homebirth a complication, and as much as we want to think of ourselves as attending normal birth, the bottom line is that a homebirth is not a normal birth from the insurance point of view.  I feel grateful that there is a "complication" code such as 659.8 that just means that there were other indications for extra care.  So, I think that does a much better job of describing the reason for the services provided by a homebirth midwife.  And. technically, Diagnosis Code 650 is for use in cases when a woman is ADMITTED for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode.  Code 650 is always a principal diagnosis, not to be used when any other code from chapter 11 is needed (codes 630-676), but you need to use 659.81 (from Chapter 11) to explain why you were there for labor monitoring/management and postpartum monitoring/management beyond the scope of 59400.  So . . . my advice . . . don't use 650 at all for a homebirth.]
 
 
Diagnosis Item #
ICD-9 Code
Description
1
659.81
Other specified indication for care or intervention related to labor and delivery, delivered
2
659.61
Elderly Multigravida delivered
3
V27.0
Single liveborn - this is the "outcome" of the birth - some use it, some don't
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
59409
Vaginal Delivery Only  (I used to bill 59400 - Global routine OB care, but that's an inappropriate way to describe the services provided by a homebirth midwife, so now I break down all the services and bill for the exact services provided, including separate charges for each prenatal appointment!) [Bill this separately to avoid incorrect concerns about "bundling"]
1, 2, 3
$2792.76
1
MM DD YY
12
99350-25
Home visit for the eval & mgnt of an established pt (needed as a companion code for 99354/99355)
1, 2
$259.72
1
MM DD YY
12
99354-25
Prolonged outpatient face-to-face; first hour
1, 2
$370.00
1
MM DD YY
12
99355-25
16  units @ $180 - of Prolonged service in outpatient setting (each add'l half hour before birth) minus 1 hour counted in 59400 minus another hour counted in 99350 minus another hour counted in 99354 - care beyond the scope of 59400 - Don't forget to put "Homebirth" in Box 19
1, 2
$2880.00
16
MM DD YY
12
99056
Home Services
1, 2
$29.60
1

And suppose you use some supplies or medications.  Here's how you might bill for them:
Diagnosis Item #
ICD-9 Code
Description
1
659.81 Other specified indication for care or intervention related to labor and delivery, delivered
2
659.61 Elderly Multigravida delivered
3
656.31 Fetal distress affecting management of mother, delivered
4
666.02 Third-stage postpartum hemorrhage, with delivery
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
A4550
Surgical Repair Tray/SterileSet-up
1, 2
$197.10
1
MM DD YY
12
S8415
Supplies for home delivery of infant
1, 2

1
MM DD YY
12
E1399
Goods Provided [Need to provide attachment re:portable warm water immersion tub for aquatherapy]
1, 2
$250.00
1
MM DD YY
12
J2590
Pitocin up to 10 units
4
$12.00
1
MM DD YY
12
J2210
Methergine up to 0.2 mg
4
$12.00
1
MM DD YY
12
E0443
Oxygen for mother - 1 unit = 5 cubic feet Tank Size D (diagnosis? Hemorrhaging? Fetal distress?)
3
$50.00
1
MM DD YY
12
A4620
Variable Concentration Mask
3
$45.00
1
MM DD YY
12
A4616
Tubing
3
$7.00
1

NOTE - You may need to attach copies of your purchase invoices for these goods.

And don't forget to bill for the baby's care!!!  Obviously, this is beyond the scope of 59400, because OBs do not provide this care for typical hospital births:
Diagnosis Item #
ICD-9 Code
Description
1
V30.2
Single liveborn born outside hospital & not hospitalized - Principal Diagnosis if the birth occurred during this episode of care - used only ONCE at the place where born - NOT for followup! 
2
V29.9
Observation and evaluation of newborns and infants for unspecified suspected condition not found
3
770.81
Primary apnea of newborn
4
779.31
Feeding problem, newborn [For insurance companies that don't cover "preventive" care at home, such as Blue Shield, you may find that you need to use a code such as this to get this care covered, even in states where in-home coverage is mandated within 48 hours of birth.] NOTE - This changed from 779.3 in 2010.
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
99465
Newborn Resuscitation (PPV and/or CPR) [Code 99465 is not reported in conjunction with code 99464 for attendance at delivery and initial stabilization of a newborn. Physicians may separately report the provision of standby services (99360) and/or initial newborn care (e.g, 99460, 99468, or 99477) on the same date as resuscitation, 99465.]
3
$414.48
1
MM DD YY
12
99344 [some use 99432 instead]
Home-New-Newborn Exam-Comp.history exam mod.decision-60min [NOTE - If plan has a homebirth exclusion, try to do the newborn exam on the next day.]
1, 2, 4
$267.12
1
MM DD YY
12
36415
Blood Draw vein/heel (placental or cord blood)
2
$17.50
1
MM DD YY
12
86900
Blood Typing; ABO
2
$15.00
1
MM DD YY
12
86901
Blood Typing; Rh (D)
2
$19.75
1

And you might use some specialty supplies and medications for the baby, too!
 
 
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
J3430 [or
E934.3 or 90782]
Phytonadione (vitamin K) per 1 mg 
??
$10.00
1
MM DD YY
12
99070
Eye Treatment
??
$10.00
1
MM DD YY
12
E0443
Oxygen for baby -  1 unit = 5 cubic feet Tank Size D (diagnosis? Respiratory Distress Syndrome?)
3
$50.00
1
MM DD YY
12
E0452
Disposable Neonatal Resuscitator - Ambu-Bag
3
$45.00
1
MM DD YY
12
A4624
Mucous Suction Device (DeLee)
3
$10.00
1
MM DD YY
12
K0190
Disposable Canister used w/Suction Pump (Res-Q-VacReplacement Unit)
3
$13.00
1
MM DD YY
12
K0192
Disposable Tubing used w/Suction Pump (Res-Q-VacReplacement Unit)
3
$7.00
1

NOTE - You may need to attach copies of your purchase invoices for these goods.

Oh, and don't forget to file claims for the services of your assistant, assuming she's licensed and/or NRP certified.  After all, she's replacing an entire neonatal team!  If you do end up having to resuscitate the baby, you could bill for that procedure, too.  However, there are complicated rules about which standby/attendance/resuscitation codes you can report in combination; try reading the Attendance at Delivery & Stabilization from the AAFP.
Diagnosis Item #
ICD-9 Code
Description
1
V29.9
Observation and evaluation of newborns and infants for unspecified suspected condition not found
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
 99360-32
Code 99360 is reported with 1 unit of service for each full 30 minutes of standby. [Not used in combination with 99464.]
1
$???
1
MM DD YY
12
99464-32
Attendance at delivery (when requested by delivering physician) and initial stabilization of newborn [Don't combine with 99360.]
1
$211.94
1
MM DD YY
12
99465-32
Newborn Resuscitation (PPV and/or CPR) [Code 99465 is not reported in conjunction with code 99464 for attendance at delivery and initial stabilization of a newborn. Physicians may separately report the provision of standby services (99360) and/or initial newborn care (e.g, 99460, 99468, or 99477) on the same date as resuscitation, 99465.]
1
$???
1
MM DD YY
12
99354-32
Prolonged outpatient face-to-face; first hour
1
$370.00
1
MM DD YY
12
99355-32
16 units @ $60 - of Prolonged service in outpatient setting (each add'l half hour) - assistant  [An assistant's hourly rate might be more if she's also a midwife.]
1
$960.00
16
MM DD YY
12
99056-32
Home Services
1
$29.60
1

 
 

Postpartum Care for the Mother

Most homebirth midwives provide home visits to check up on the mom and baby around 24 and 48 hours.  In California, insurance companies are required by the "No Drive Through Delivery" legislation to cover this care, even if there are no complications.  And it's not unusual for mothers to have miscellaneous other problems occur, anyway - engorgement, nipple trauma, subinvolution of the uterus, etc.

Bill for office or Home visit of appropriate length - this billing shows 3 comprehensive home visits (1, 2 and 5 days), then a 10-day office visit with a fingerstick to check hemoglobin, and a six-week visit.  Some insurance companies will only pay for the postpartum visits after 48 hours if there are complications.  Here are the most common ones:


 
 
Diagnosis Item #
ICD-9 Code
Description
1
V24.1
Postpartum Care and Examination of Lactating Mother - supervision of laceration

In the example, below, the modifier -32 is for mandated coverage of in-home postpartum care within 48 hours of the birth, applicable in California and some other states?  The modifer -24 is for office visits focused on lactation consulting, which is not included in 59400, or if you're doing a fingerstick to diagnose anemia.
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
99350-32
Estab-Comp.-60min
1
$259.72
1
MM DD YY
12
99350-32
Estab-Comp.-60min
1
$259.72
1
MM DD YY
12
99350-24
Estab-Comp.-60min
1
$259.72
1
MM DD YY
11
99214-24
Est. Client comprehens. OV (postpartum office visits)
1
$115.06
1
MM DD YY
11
36415-24
Blood Draw finger stick - Hgb
1
$17.50
1
MM DD YY
11
99214-24
Est. Client comprehens. OV (postpartum office visits)
1
$115.06
1

RhoGAM for RH-Negative Moms [ This section under construction!]

For moms who are Rh-Negative and have a baby with positive RH, here's what the prenatal and postpartum RhoGAM might get billed as:
 
 
Diagnosis Item #
ICD-9 Code
Description
1
V07.2
Need for prophylactic immunotherapy - administration of RhoGAM

 
 
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
90385
Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use
1
$150.00
1
MM DD YY
12
90384
Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use (J2790 and J2792 discontinued 7/1/2001)
1
$150.00
1
If you need to test the father's blood for the Rhesus factor, you can try this diagnosis code:

V78.8 - Screening for other disorders of blood or blood-forming organs.  (It seems like there should be a better diagnosis, but I sure don't know it!)
 
 

Alternative Package Deal

Some midwives recommend negotiating a "package deal" with the insurance company early in prenatal care.  It's a simple argument that this care is less expensive than hospitalization.
 
 
Diagnosis Item #
ICD-9 Code
Description
1
650
Normal birth
2
V24.0
Postpartum care and examination immediately after delivery (non-routine care, beyond 59400)
3
V24.1
Postpartum care and examination of lactating mother (non-routine care, beyond 59400)
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
Birth Date
12
59400
Global routine OB care - up to 13 prenatal visits
1
$2792.76
1
Birth Date
12
59899-25
Unlisted procedure, maternity care and delivery [In lieu of hospitalization for labor, birth and immediate postpartum. Comprehensive labor management, monitoring and nursing care, up to 8 hours before the birth and 6 hours after the birth.]
1, 2
$3700.00
1
1st Day After Birth
12
99350-32
Estab-Comp.-60min [In lieu of hospitalization for 1st full day after birth.]
3
$405.00
1
2nd Day After Birth
12
99350-32
Estab-Comp.-60min [In lieu of hospitalization for 2nd full day after birth.]
3
$405.00
1

The above maternity package is clearly less expensive than routine hospitalization for labor, birth and 48 hours postpartum.

Newborn Care

There aren't any codes specifically for the care of a newborn at a homebirth, so different midwives use different codes:

Here are some references to help you decide which make most sense to you - note that some of these are specifically for the first newborn exam, some for followup care, and some for paperwork.  It's hard to know whether to apply these codes to homebirth if they specifically refer to hospital or birth center admissions:

History and Physical: Newborn - from the AAFP - search for 99431

Coding Prep School take on the subject

Newborn Followup Care - This baby had some latch difficulties at the first and second followup visits, and jaundice on Days 2, 5 and 10.
Diagnosis Item #
ICD-9 Code
Description
1
779.31
Feeding problem newborn - use only if faulty feeding, i.e. poor latch, suck reflex or swallow.  NOTE - This changed from 779.3 in 2010.
2
774.6
Unspecified fetal & neonatal jaundice
3
V29.9
Observation and evaluation of newborns and infants for unspecified suspected condition not found
4
V20.2
Routine Infant Or Child Health Check - Developmental testing of infant (> 28 days) or child 

In the example, below, the modifier -32 is for mandated coverage of in-home postpartum care within 48 hours of the birth, applicable in California and some other states? [NOTE - Blue Cross of California pays less for a home visit than an office visit, which seems a little crazy to me, and it seems especially crazy to require a new mom and baby to come to your office so they get good reimbursement, but . . . that's what Blue Cross of California is pressuring us to do!]
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
99350-32
12-Estab-Comp.-60min
1, 3
$259.72
1
MM DD YY
12
99350-32
12-Estab-Comp.-60min
1, 2, 3
$259.72
1
MM DD YY
12
99350
12-Estab-Comp.-60min
2, 3
$259.72
1
MM DD YY
11
99214
Est. Client comprehens. OV 
2, 3
$115.06
1
MM DD YY
11
99211
Est. Client limited OV (6-week baby weight check)
4
$26.92
1

Newborn Screen for California - These are the codes provided by the State of California's NBS program as of January 1, 2012 - $111.70 for the lab fee - practitioner may bill $1 for the specimen collection form and up to $6 for drawing and handling.
 
Diagnosis Item #
ICD-9 Code
Description
1
V77.3
V77.3 - Screening for phenylketonuria (PKU) - The State of California's NBS program recommends the use of diagnosis code V77.3 for the entire screening panel.
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
82776-32
Galactose-1-phosphate uridyl transferase
1
$15.95
1
MM DD YY
12
83021-32
Hemoglobin fractionation and quantitation; chromatography
1
$15.95
1
MM DD YY
12
83498-32
Hydroxyprogesterone, 17-d (17-OHP)
1
$15.95
1
MM DD YY
12
83789-32
Tandem mass spectrometry; quantitative (MS/MS)
1
$16.00
1
MM DD YY
12
84443-32
Thyroid Stimulating Hormone (TSH)
1
$15.95
1
MM DD YY
12
82261-32
Biotinidase (BD)
1
$15.95
1
MM DD YY
12
83516--32
Immunoreactive trypsinogen (IRT)
1
$15.95
1
MM DD YY
12
81479-32
T-Cell Receptor Excision Circles (TRECs) [As of March 1, 2013, the California Newborn Screening Program is including a screening for Severe Combined Immunodeficiency (SCID), but they are not raising the fee at this time.  It doesn't make sense to bill for something for which there's no charge, but I'm assuming they'll be including an extra fee sometime in the near future.]
1
$0.00
1
MM DD YY
12
36416-32
Collection of capillary blood specimen (eg finger heel ear stick) - Newborn Screen - fee limited by law to $7
1
$7.00
1

Skilled Nursing Care

Some midwives bill their time beyond 59400 as skilled nursing care.  [I have mixed feelings about this because it fails to acknowledge the amount of responsibility that the midwife takes on as the primary care provider!] Some resources state that the provider must be an RN, and others state that "these codes are used by non-physician health care professionals.  Health care professionals who are authorized to use Evaluation and Management Home Visit codes (99341-99350) may report 99500-99600 in addition to 99341-99350 if both services are performed.  Evaluation and Management services may be reported separately, using modifier 25, if the patient's condition requires a significant separately identifiable E/M service, above and beyond the home health service(s)/procedure(s) codes 99500-99600."

(The links here are into the North Carolina web pages - there may be better sources of information)
99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring
99501 Home visit for postnatal assessment and follow-up care
99502 Home visit for newborn care and assessment
99506 Home visit for intramuscular injections (for RhoGAM injection)
99600 Unlisted home visit service or procedure (unlimited possibilities here)

Equipment

Midwives typically bring to births equipment which they have purchased and maintained.  At a typical hospital or birth center birth, the facility provides all this equipment, so it is not included in the procedure codes for birth.  Therefore, midwives may bill additionally for this equipment as rental of medical equipment.  [I have found absolutely nothing else to help with this, so if you have any better ideas, please send them to me: my username is ronnie, and I'm at gentlebirth.org.  Please put the word "midwife" in the subject line to get through the spam filters.  Thanks!]

Some key points - you're not selling the equipment, you're renting it to them for the time you're there.
 
 
Diagnosis Item #
ICD-9 Code
Description
1
650
Normal Birth
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
E1399-RR
Huntleigh First Assist Portable Continuous Electronic Fetal Monitor [RR means Rental]
1
$160.00
1
MM DD YY
12
E0445-RR
BCI FingerPrint Pulse Oximeter 3401device for measuring blood oxygen levels non-invasively [RR means Rental]
1
$70.00
1
MM DD YY
12
E0731-RR
BabyCare Femme Obstetric TENS [RR means Rental]
1
$30.00
1

NOTES - CIGNA allowed this approach Feb., 2007
NOTES - United Healthcare allowed this approach Feb., 2007

Birthing Tub Rental

In billing for the birthing tub rental, I had to file a separate claim since the software choked on having two separate items of E1399 -
"AQUADOULA BIRTHING TUB IN LIEU OF EPIDURAL ANESTHESIA" in Box 19 or "Other Claim Info"
 
 
Diagnosis Item #
ICD-9 Code
Description
1
650
Normal Birth
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
E1399-RR
Miscellaneous Equipment-Rental [Don't forget Box 19!]
1
$250.00
1

NOTES - CIGNA allowed this approach Feb., 2007
NOTES - United Healthcare wanted more info, so I sent an "Order for DME" and a copy of my AquaDoula purchase invoice.

Billing for Labor Support/Doula Work

Because midwives promise continuity of care, it is often the standard of care that if the client needs to transfer care to a hospital-based provider, they will go with the client to the hospital to be with them and provide labor support services, often including breastfeeding assistance after the birth.

In this example, let's say that the labor actually starts at home, but then there is a stall during labor.  The time spent at home is a different episode of care and does not include the delivery (i.e. the birth), so that has a different diagnosis code from the time spent in the hospital, which does result in the delivery.

This approach could be used to bill for a transport, but that's really more complicated since you also need to bill for the prenatal care and the responsibility associated with midwifery services.
 
 
Diagnosis Item #
ICD-9 Code
Description
1
661.13
Secondary uterine inertia - Arrested active phase of labor, antepartum [NOTE that the final 3 indicates that the birth did NOT happen during this episode of care.]
2
661.11
Secondary uterine inertia - Arrested active phase of labor, with delivery [NOTE that the final 1 indicates that the birth DID happen during this episode of care.]
3
V24.2
Routine Postpartum Followup [NOTE that the final  2 indicates that this postpartum care happened during the same episode of care as the birth, i.e. it was in the IMMEDIATE Postpartum, not a followup appointment.]
DATE(S) OF 
PLACE OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
Description
DIAGNOSIS CODE
$ CHARGES
DAYS OR UNITS
MM DD YY
12
99350
Home visit for the eval & mgnt of an established pt - This is the primary service for labor support in the home!
1
$259.72
1
MM DD YY
12
99354
Prolonged outpatient face-to-face; first hour
1
$370.00
1
MM DD YY
12
99355
10  units @ $180 - of Prolonged service in outpatient setting (each add'l half hour) [You should bill for the actual number of units provided, i.e. number of hours * 2]
1
$1800.00
10
MM DD YY
21
99356
Prolonged service in inpatient setting (first hour after going to hospital)
2
$177.64
1
MM DD YY
21
99357
5  units @ $180 - of Prolonged service in inpatient setting - duration of labor and first hour postpartum to assist with breastfeeding (each add'l half hour) [You should bill for the actual number of units provided, i.e. number of hours * 2]
2, 3
$900.00
5

 

Billing for a Transport

Washington State provides guidelines for billing for a Transport:

"Labor Management - Prolonged services codes must be billed on the same claim form as E&M codes, and modifier TH and one of the diagnoses listed below must be on each detail line of the claim form:

Codes:
99211-99215 TH: Office visits - labor at home or birthing center
+99354 TH: Prolonged services, 1st hour (Limited to 1 unit)
+99355 TH: Prolonged services - each addl 30 minutes (Limited to 4 units) [Ed: Whom are they kidding - total 3 hours!?!]
(Diagnoses 640-674.9; V22.0-V22.2; and V23-V23.9; must have -TH to pay with these diagnoses; may not be billed by delivering physician.)
Note: Providers may bill MAA for labor management only when the client is transferred to a hospital; another provider delivers the baby; anda referral is made during active labor."
 



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