Maternity Services

[Pages:6]Office of Maternal, Child and Family Health

Maternity Services

(Non-Medicaid & Non-CHIP Enrollees) Fee Schedule

Effective July 1, 2021

Procedure

01961

01965

01967

01968

Procedure 54150 54160 59000 59020 59020-TC 59020-26 59025 59025-TC 59025-26 59120

59150 59320 59409 59410 59430 59514 59515 59812 59820 59821

(Available at rfts - requires user name and password available from OMCFH) Description

Rate

Anesthesia for cesarean delivery only

Base 7 units $22.70 x 7 = $158.90 (7 base unit) $22.70 x units on bill (Max 8 units) = X

$158.90 + X = Total payment

Anesthesia for missed abortion

Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor

Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed)

Base 4 units $22.70 x 4 = $90.80 (4 base unit) $22.70 x units on bill (Max 8 units) = X

$90.80 + X = Total payment

Base 5 units $22.70 x 5 = $113.50 (5 base unit) $22.70 x units on bill (Max 8 units) = X

$113.50 + X = Total payment

Base 2 units (01967) $22.70 x 5=$113.50 (5 base unit) (01968) $22.70 x 2=$45.40 (2 base unit)

$22.70 x units (01967 & 01968) on bill (Max 8 units) = X

$113.50 + $45.40 + X = Total payment

Description Circumcision, using clamp or other device; newborn Circumcision, surgical excision other than clamp, device or dorsal slit; newborn Amniocentesis; diagnostic Fetal Contract Stress Test Fetal Contract Stress Test Fetal Contract Stress Test Fetal Non-Stress Test Fetal Non-Stress Test Fetal Non-Stress Test

Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach

Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy Cerclage of cervix, during pregnancy; vaginal Vaginal delivery only (with or without episiotomy and/or forceps) Vaginal delivery only (with or without episiotomy and/or forceps) including postpartum care Postpartum care only (separate procedure) Cesarean delivery only Cesarean delivery including postpartum care

Treatment of incomplete abortion; any trimester, completed surgically

Treatment of incomplete abortion; any trimester, completed surgically

Treatment of missed abortion; second trimester, completed surgically

Facility 1 $67.24

$98.57 $55.43 $46.27 $20.49 $25.55 $32.78 $11.81 $20.97

$569.00

$552.13

$105.56 $749.28

$983.87 $167.74 $850.82 $1,214.95 $212.80

$260.28

$257.63

Non - Facility 1 101.46

$146.77 $79.53 $46.27 $20.49 $25.55 $32.78 $11.81 $20.97

$569.00

$552.13

$105.56 $749.28

983.87 $231.40 $850.82 $1,214.95 $244.37

$290.89

$289.44

WVDHHR BPH OMCFH Maternity Services Fee Schedule July 2021

Page 1

Procedure 64450

76801

76801-TC 76801-26

76802

76802-TC 76802-26

76805

76805-TC 76805-26

76810

76810-TC 76810-26

76811

76811-TC 76811-26

76812

76812-TC 76812-26

76815

76815-TC 76815-26

76816

76816-TC 76816-26 76817 76817-TC 76817-26 76818 76818-TC 76818-26 76819 76819-TC 76819-26

Circumcision nerve block

Description

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 wks 0 days), transabdominal approach; single or first gestation

Technical Component Professional Component

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 wks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

Technical Component Professional Component

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 wks 0 days), transabdominal approach; single or first gestation

Technical Component Professional Component Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 wks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

Technical Component Professional Component Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation Technical Component Professional Component Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) Technical Component Professional Component Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses

Technical Component Professional Component Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

Technical Component Professional Component Ultrasound, pregnant uterus, real time with image documentation, transvaginal

Technical Component Professional Component

Fetal biophysical profile; with non-stress testing Technical Component Professional Component Fetal biophysical profile; without non-stress testing Technical Component Professional Component

Facility 1 $28.92

Non - Facility 1 $50.61

$77.36

$44.59 $32.78

$77.36

$44.59 $32.78

$40.97

$40.97

$13.50 $27.72

$88.69

$55.91 $32.78

$13.50 $27.72

$88.69

$55.91 $32.78

$59.05

$26.51 $32.54

$113.51 $51.09 $62.42

$127.01

$68.44 $58.32

$53.74 $31.81 $21.93

$59.05

$26.51 $32.54

$113.51 $51.09 $62.42

$127.01

$68.44 $58.32

$53.74 $31.81 $21.93

$72.06

$72.06

$43.86 $28.20

$61.21

$36.15 $25.06 $74.71 $40.01 $34.70 $55.43 $29.64 $25.79

$43.86 $28.20

$61.21

$36.15 $25.06 $74.71 $40.01 $34.70 $55.43 $29.64 $25.79

WVDHHR BPH OMCFH Maternity Services Fee Schedule July 2021

Page 2

Procedure 76946 76946-TC 76946-26

80053

80055

81000

81001

81002

81003 81005 81015 81025 82105 82570 82947 82950 82951 84156 84702 85014 85018 85025 85027 86580

Description Ultrasonic guidance for amniocentesis, imaging supervision and interpretation Technical Component Professional Component

Facility 1

$20.97 $8.44

$12.53

Comprehensive metabolic panel. This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium (82310), Carbon dioxide (bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84460), Urea nitrogen (BUN) (84520). Do not use 80053 in addition to 80048, 80076 (HepB).

Lab2

$9.50

Obstetric panel. This panel must include the following: Blood count, complete (CBC) , automated and automated differential WBC count (85025 or 85027 and 85004) or Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), Hepatitis B surface antigen (HBsAg) (87340), Antibody, rubella (86762), Syphilis test, qualitative (e.g. VDRL, RPR, ART) (86592), Antibody screen, RBC, each serum technique (86850), Blood typing, ABO and Blood typing Rh (D) (86901).

Lab2

$43.03

Urinalysis by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any Lab2 number of these constituents; non-automated, with microscopy

$3.62

Urinalysis by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any Lab2 number of these constituents; automated, with microscopy

$2.85

Urinalysis by dipstick or tablet reagent for bilirubin, glucose, hemoglobin,

ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any Lab2 number of these constituents; non-automated, without microscopy

$3.13

Urinalysis by dipstick or tablet reagent for bilirubin, glucose, hemoglobin,

ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any Lab2 number of these constituents; automated, without microscopy

Urinalysis; qualitative or semiquantitative, except immunoassays

Urinalysis; qualitative or semiquantitative, except immunoassays microscopic only Urine pregnancy test, by visual color comparison methods Alpha-fetoprotein; serum Creatinine; other source Glucose; quantitative, blood (except reagent strip) Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), three specimens (includes glucose) Protein, total, except by refractometry, urine Gonadotropin, chorionic (HCG); quantitative Blood count; hematocrit (Hct) Blood count; hemoglobin (Hgb) Blood count; automated differential WBC; complete count (CBC); automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count

Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Skin test; tuberculosis, intradermal

Lab2

Lab2

Lab2 Lab2 Lab2 Lab2 Lab2 Lab2 Lab2 Lab2 Lab2 Lab2

Lab2

Lab2

$2.03

$1.95 $2.75 $7.75 $15.09 $4.66 $3.54 $4.28 $11.58 $3.30 $13.55 $2.13 $2.13

$6.99

$5.82 $6.03

Non - Facility 1 $20.97 $8.44 $12.53

$6.03

WVDHHR BPH OMCFH Maternity Services Fee Schedule July 2021

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Procedure 86701 86803 87070 87081 87086 87088 87110 87149 87210

87220

87252 87254

87340 87490 87491 87590 87591 88141

88142

88164

90384 99213-TH 99238

99460

99463

99464

Description

Facility 1

HIV -1

Lab2

$8.00

Hepatitis C antibody

Lab2

$12.84

Culture, bacterial; any other source except urine, blood or stool, aerobic,

with isolation and presumptive identification of isolates

Lab2

$7.76

Culture, presumptive, pathogenic organisms, screening only

Lab2

$5.97

Culture, bacterial; quantitative colony count, urine

Lab2

$7.26

Culture, bacterial; with isolation and presumptive identification of isolates, urine

Lab2

$7.28

Culture, Chlamydia, any source Culture, typing; identification by nucleic acid probe Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps)

Lab2 Lab2

Lab2

$17.64 $18.05

$5.24

Tissue examination by KOH slide of samples from skin, hair or nails for

fungi or ectoparasite ova or mites (e.g., scabies)

Lab2

$3.84

Virus isolation; tissue culture inoculation, observation and presumptive identification by cytopathic effect

Lab2

$23.46

Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Hepatitis B surface antigen (HBsAg)

Lab2 Lab2

$17.60 $9.30

Chlamydia trachomatis, direct probe Chlamydia trachomatis, amplified probe technique Neisseria gonorrhoeae, direct probe technique Neisseria gonorrhoeae, amplified probe technique

Cytopathology, cervical or vaginal (any reporting system) requiring interpretation by physician Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

Lab2 Lab2 Lab2 Lab2

Lab2

$20.48 $31.58 $24.19 $31.58 $13.98

$18.23

Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

Lab2

$13.64

4Rho (D) immune globulin (Rhlg), human, full dose, for intramuscular use

Not Covered

3Office/Outpatient Visit Prenatal Hospital discharge day management; 30 minutes or less

$60.16 $47.96

History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. (This code should also be used for birthing room deliveries.)

$64.35

History and examination of the normal newborn infant, including the preparation of medical records. (This code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date.)

$73.75

Attendance at delivery (when requested by delivering physician) and initial stabilization of newborn

$50.13

Non - Facility 1

$13.98 Not Covered

$79.26 $47.96 $64.35 $73.75 $50.13

1 Facility and Non-Facility fees are based on the 2021 RBRVS. A copy of this report can be downloaded at: 's-RBRVS-Fee-Schedules.aspx

2 Lab fees are based on CLAB2021 schedule. A copy of this schedule can be downloaded at:

3 Limited to 20 visits for a six-month time period.

4 Carrier-priced procedure code: Medicaid will establish the fee for services considered unlisted CPT procedure codes and for services for which CMS has not established "relative value units", typically low-volume services. Invoices are priced on an individual basis and the yearly fees rarely changes.

WVDHHR BPH OMCFH Maternity Services Fee Schedule July 2021

Page 4

Office of Maternal, Child and Family Health

Maternity Services

Fee Schedule Legend

Place of Service

03 04 05 06 07 08 09 11 12 13 14 15 20 21 22 23 24 25 26 31 32 33 34 41 42 49 50 51 52 53 54 55 56 57 60 61 62 65 71 72 81 99

Description

School Homeless Shelter Indian Health Service Free-Standing Facility Indian Health Service Provider-Based Facility Tribal 638 Free-Standing Facility Tribal 638 Provider-Based Facility Prison - Correctional Facility Office Visit Home Assisted Living Facility Group Home Mobile Unit Urgent Care Facility Inpatient Hospital Outpatient Hospital Emergency Room Ambulatory Surgical Center Birthing Center Military Treatment Facility Skilled Nursing Facility Nursing Facility Custodial Care Facility Hospice Ambulance - Land Ambulance - Air or Water Independent Clinic Federally Qualified Health Center Inpatient Psychiatric Facility Psychiatric Facility Partial Hospitalization Community Mental Health Center Intermediate Care / Mentally Retarded Residential Substance Abuse Treatment Psychiatric Residential Treatment Non-residential Substance Abuse Treatment Facility Mass Immunization Center Comprehensive Inpatient Rehab Comprehensive Outpatient Rehab End Stage Renal Disease State or Local Public Health Clinic Rural Health Clinic Independent Laboratory Other Unlisted Facility

Facility or Non-Facility

NF NF NF NF NF NF NF NF NF F F NF F F F F F F F F F F NF NF NF NF NF F F NF F F F NF NF F F F NF NF NF F

WVDHHR BPH OMCFH Maternity Services Fee Schedule July 2021

Page 5

Office of Maternal, Child and Family Health Maternity Services

(Non-Medicaid or Non-CHIP Enrollees) Hospital Delivery Rates Fee Schedule

Eff July 1, 2021

DRG Code 786

Description Cesarean Section with complications

788

Cesarean Section without complications

806

Vaginal Delivery with complications

807

Vaginal Delivery without complications

Rate $5,000.00 $5,000.00 $5,000.00 $5,000.00

Hospital charges for the mother (vaginal or c-section), hospital supplies, and laboratory work is limited to $5,000 in total for each live birth delivery.

NON Covered Services: ? Hospitalization at any time other than for delivery; ? Observation status at the hospital; ? Intermediate or intensive care for the mother or newborn; ? Any service/care that is not pregnancy related; ? Emergency room charges/care; ? Ambulance services; ? Family planning services/postpartum sterilization (woman must be referred to the OMCFH Family Planning Program (FPP)); ? Infant care rendered after discharge from the hospital; and ? Infant care other than routine newborn care.

WVDHHR BPH OMCFH Maternity Services Fee Schedule July 2021

Page 6

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