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

Sample Billing Scenarios for a Homebirth Midwife

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

General Information

Completing the HCFA Form

Diagnosis Item #

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

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

• 11 - Office
• 12-  Home
• 21 - Inpatient Hospital
• 25 - Birthing Center

CPT-4 # - Procedures, Services, Or Supplies

MODIFIERS

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

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

Days or Units

Timing the Filing Of Claims

[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

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

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

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:

• [coming soon]

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!]

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

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

Newborn Care

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

(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

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

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

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

"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."