Modifier Coding Alert

Published on Wed Jul 16, 2014 PDF

Question: I am getting denials from a Medicaid Care Management Organization (CMO)Amerigroup, for deliveries stating the procedure requires the correct modifier. I can’t find anything about Amerigroup requiring a modifier for deliveries nor have I received any notifications. I called Amerigroup and they won’t assist with information. What modifier is appropriate in these cases?

Georgia Subscriber

Answer: If your payer is Georgia Medicaid/Amerigroup/Wellcare, you’ll use modifiers:

• UB (Medicaid level of care 11, as defined by each state) for medically necessary delivery prior to 39 weeks gestation (for deliveries resulting from members presenting in labor, or at risk of labor, and subsequently delivering before 39 weeks.
• UC (Medicaid level of care 12, as defined by each state) for delivery at 39 weeks of gestation or later (for all deliveries at 39 weeks gestation or more regardless of method induction, c-section, or spontaneous labor).
• UD (Medicaid level of care 13, as defined by each state) for non-medically necessary delivery prior to 39 weeks gestation (elective non-medically necessary deliveries less than 39 weeks gestation).

Effective July 1, 2013, Medicaid fee-for-service claims (October 1, 2013 for Medicaid Managed Care and FHPlus claims) submitted by practitioners for obstetric delivery procedure codes 59400-59410 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care), 59510-59515 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care), 59610-59622 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery) require a modifier. 

Provider claims for obstetric deliveries must include one of the following modifiers. Failure to include one of the two modifiers on a claim will result in denial. 

Depending on the gestation period, you will use either U8 (Medicaid level of care 8, as defined by each state) if delivery was prior to 39 weeks of gestation or U9 (Medicaid level of care 9, as defined by each state) if delivery was at 39 weeks of gestation or later.

Note: In some states, you need different modifiers. For example, in Texas the modifiers are:

• U1 (Medicaid level of care 1, as defined by each state) for deliveries less than 39 weeks and medically necessary
• U2 (Medicaid level of care 2, as defined by each state) for deliveries greater than 39 weeks.