Question Texas Deliveries

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Needing help with our local Medicaid product denying our deliveries prior to 39 gestational weeks. Per the delivery note the patient has a 1st or 2nd degree laceration which is what we use for a diagnosis but it is not listed as a payable dx.
Has anyone else incurred similar challenges? If so how are you appealing these denials?
 

tpkeith

Networker
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47
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Dalton, Georgia
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Georgia Medicaid has also decided not to pay for 'elective' deliveries prior to 39 weeks. However, anything with a gestation of less than 39 weeks gets denied. There is a Joint Commission listing under Table Number 11.07 - Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation which might be helpful to you. You should be able to find this online. We have requested a diagnosis listing from Medicaid and CMOs, but they just won't give us a list. We have to appeal most every one of these denials.
 

SharonCollachi

True Blue
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1,201
Location
Clovis, CA
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Okay, now I get it. The patient had a laceration PRIOR to delivery and that's why she was induced? That seems to be what you are saying. So what, EXACTLY, is the reason she delivered prior to 39 weeks?

This document, although from NY, seems to cover it pretty well, although the embedded links are not working for me: https://www.emedny.org/ProviderManu...AL_DELIVERIES_PRIOR_TO_39_WEEKS_GESTATION.pdf

Here is an alternate to the embedded link, which lists medical indications for delivery prior to 39 weeks (scroll down to the beige box): https://www.acog.org/clinical/clini...eliveries-and-associated-neonatal-morbidities
 
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I'm sorry so patient came in active labor at 38 weeks. She delivered and tore during delivery. We use the laceration code for the delivery currently as primary. There are no other complications and we have been incurring denials. One payer is saying we need to be using the O80 but from what I read in the coding guidelines if we use O80 then we can not use another dx in the same chapter. Thoughts??
 

csperoni

True Blue
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Selden
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Not in Texas, and don't really bill deliveries, but I know there are U modifiers required by NY Medicaid.
What exact CPT/modifier/ICD10 are you billing and what exactly is the denial?
And yes, O80 states not to bill with any other O code, and to add Z37.0-Z37.9 for outcome of delivery.
 
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