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Non Payment Policy for Deliveries Prior to 39 weeks: Birth Outcomes Initiative

Medicaid Agency to Stop Payment for Elective Early Deliveries

Aims to Improve Health of Newborns, Reduce Preterm Births in South Carolina

 

COLUMBIA, S.C. - Starting this month, the South Carolina Department of Health and Human Services (SCDHHS) will no longer provide reimbursement to hospitals and physicians for elective inductions or non–medically indicated deliveries prior to 39 weeks gestational age. This applies to both inductions of labor and cesarean sections. With broad support from the health care community, this policy implementation is championed by the South Carolina Birth Outcomes Initiative (BOI), a collaboration formed in 2011 among SCDHHS, the South Carolina Hospital Association, the South Carolina Obstetrical and Gynecological Society, the South Carolina Chapter of the March of Dimes, maternal fetal medicine physicians from all five regional perinatal centers, BlueCross Blue Shield of South Carolina (BCBSSC) and other stakeholders.

The inclusion of BCBSSC, which has its own comprehensive programs for increasing healthy birth outcomes, is integral to the success of the state’s efforts. Together SCDHHS and BCBSSC cover approximately 85 percent of all South Carolina births annually. Medically-indicated delivery reimbursement remains unchanged.

In the last year, non-medical inductions prior to 39 weeks have been reduced by half as a result of a BOI-sponsored commitment from all 43 birthing hospitals in South Carolina to end the practice.

“Together with hospitals, doctors and the private sector, we are serious about improving the health of babies in our state. We’ve already seen these deliveries reduced by half,” said SCDHHS Director Tony Keck. “This first-of-its-kind collaborative effort between the State, the largest private payor and the healthcare community is an incredible step toward giving all South Carolina babies a healthy start.”

Traditionally, public health efforts have focused on preventing preterm births prior to 37 weeks gestational age.  Premature birth is the leading cause of newborn death. Babies who survive an early birth often face low birth weight and lengthy stays in a Neonatal Intensive Care Unit and are at a higher risk of corresponding lifelong health problems, such as breathing problems, cerebral palsy, intellectual disabilities and others. In 2011, 14 percent of live births in South Carolina were delivered preterm; a rate much higher than the national average of 11.7 percent.

But other infants are at risk as well.  Early term births, delivered at 37 and 38 weeks gestational age, also pose serious risks to babies and represent a significant cost to the healthcare system.  The American Congress of Obstetricians and Gynecologists (ACOG) advises against non-medically indicated elective deliveries prior to 39 weeks gestational age.  Despite these guidelines, however, there has been a national trend toward elective early labor induction and cesarean section.  South Carolina is no exception.  There were more than 6,000 early elective deliveries in 2011 in South Carolina. 

"The last few weeks of pregnancy are very important for the health of the baby," Said Dr. Amy Picklesimer, Maternal Fetal Medicine physician with Greenville Hospital System and the Clinical Lead for the BOI. “Infants who are electively delivered prior to 39 weeks have an increased risk of respiratory distress, admission to the NICU and prolonged hospitalization. There is no medical benefit to the mother. These deliveries are typically performed for scheduling convenience.”

SCDHHS through the BOI is working on other initiatives to improve the health and healthcare for pregnant women and infants in South Carolina. In 2012, a program incentivizing doctors to screen pregnant women for risk factors such as substance abuse, domestic violence and depression was started. In 2013, incentive payments will be available for providers offering CenteringPregnancy, a group model of prenatal care shown to decrease rates of preterm birth by 40 percent. SCDHHS also recently announced the "Race to the Date" program which provides financial rewards to hospitals certified as "Baby Friendly" by September 30, 2013.
 
This SCDHHS policy applies to all fee-for-service, medical home networks and managed care organization participants.
 
The South Carolina Department of Health and Human Services provides health care benefits to more than 1.1 million South Carolinians and financially supports almost half of all births in the state. Its mission is to purchase the most health for our citizens in need at the least possible cost to the taxpayer.

Non Payment Policy for Deliveries Prior to 39 weeks: Birth Outcomes Initiative

Effective for dates of service on or after January 1, 2013, the South Carolina Department of Health and Human Services (SCDHHS) will no longer provide reimbursement for elective inductions or non–medically indicated deliveries prior to 39 weeks to hospitals and to physicians.  This change is a result of an extensive effort and partnership by SCDHHS, South Carolina Hospital Association, South Carolina Chapter of the American Congress of Obstetricians & Gynecologists, Maternal Fetal Medicine physicians, BlueCross BlueShield of SC and other stakeholders to reduce non-medically necessary deliveries.

In September of 2011, through the Birth Outcomes Initiative (BOI) and South Carolina Hospital Association (SCHA), all 43 birthing hospitals in South Carolina signed a pledge to stop early elective deliveries.  In July of this year, physicians were notified that as of August 1, 2012, all claims submitted for deliveries and inductions had to contain a specific modifier (GB or CG).  Please visit http://www.scdhhs.gov/press-release/birth-outcomes-initiative-modifiersto view the SCDHSS Medicaid bulletin released in July 2012.

All hospital claims that are associated with physician claims resulting from non-medically necessary deliveries and inductions prior to 39 weeks gestation will be audited and payment will be re-couped in its entirety through a retrospective review process. 

Physicians must continue to append the following modifiers to all CPT surgical codes when billing for vaginal deliveries and cesarean sections or their claims will be automatically denied:

GB – 39 weeks gestation and or more

For all deliveries at 39 weeks gestation or more regardless of method (induction, cesarean section or spontaneous labor)

CG – Less than 39 weeks gestation

  • For deliveries resulting from patients presenting in labor, or at risk of labor, and subsequently delivering before 39 weeks, or
  • For inductions or cesarean sections that meet the ACOG guidelines, the appropriate ACOG Patient Safety Checklist must be completed and maintained for documentation in the patient’s file, or
  • For inductions or cesarean sections that do not meet the ACOG guidelines, the appropriate ACOG Patient Safety Checklist must be completed.  Additionally, the physician must obtain and document approval from the regional perinatal center’s maternal fetal medicine physician in the patients file and in the hospital record

No Modifier – Claims that do not have the GB/CG modifiers indicated will be denied

For elective deliveries less than 39 weeks gestation that do not meet ACOG approved guidelines or are not approved by the designated regional perinatal center’s maternal fetal medicine physician.

This bulletin applies to all fee-for-service, medical home networks and managed care organization participants.  If you have any questions, please contact the Provider Service Center at (888)289-0709.  Thank you for your continued support of the SC Medicaid program.