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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 3 Obstetric Services : 3.1 *Services, Benefits, Limitations, and Prior Authorization : 3.1.2 Vaginal and Cesarean Deliveries

3.1.2
The following procedure codes submitted with the appropriate modifier may be a benefit for vaginal or Cesarean deliveries:
 
The following modifiers may be billed with the procedure codes indicated above for vaginal and cesarean deliveries:
 
Claims will deny if submitted for a delivery prior to 39 weeks of gestation and not medically necessary, or for a delivery service with no modifier.
Claims will deny or recoupment will occur for associated claims for deliveries that are performed prior to 39 weeks and are determined to be not medically necessary including:
Inpatient and outpatient hospital claims inclusive of the delivery, planned Cesarean section, induction with vaginal delivery or failed induction with subsequent Cesarean section
Home deliveries must be billed with procedure code 59409 or 59410; including postpartum care.
Licensed midwives will not be reimbursed for home deliveries.

Texas Medicaid & Healthcare Partnership
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