Best Practices for Newborn Encounter Data Submission

Simplifying Healthcare Administration Created by HICE Encounters Standardization Team BEST PRACTICES FOR SUBMITTING NEWBORN ENCOUNTERS JULY 2023

INTRODUCTION Overview: Overview: This document is intended to be a resource to help educate service providers on newborn and multiple birth encounter data submissions. How How- -to to- -use: when reporting on newborns (with or without an ID) and reporting multiple births use: As a resource or training tool to educate on proper claim and encounter submissions Audience: Audience: All health care organizations, such as health plans, provider organizations, and delegates that work with capitated claims or encounters for newborn and multiple birth submissions Use cases: Use cases: Designed to be a quick resource for health care organizations to use when submitting newborn encounters that can be submitted in multiple ways/scenarios 2 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

TABLE OF CONTENTS 1. Guideline to Submit Newborn Encounters 2. Example: Newborn Submission When No (example 1: newborn submitted as a subscriber; example 2: newborn submitted as a dependent) No Newborn ID is Available 3. Example: Newborn Submission When Newborn ID is Available 4. How to Submit Multiple Newborn Encounters 5. Modifier Definitions 6. List of Diagnosis Codes to Submit Multiple Birth Newborn Encounters 7. Examples of Multiple Newborns Submitted in 837 Format 8. Sources 9. HICE Resources 3 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

GUIDELINE TO SUBMIT NEWBORN ENCOUNTERS Guideline to submit newborn encounters Guideline to submit newborn encounters Newborns can be submitted under the Mother s Health Plan ID or Client Index Number (CIN) for the month of birth, and the subsequent, or following full month. This means the baby is covered for a length of time that can vary from 32 days to 62 days. Example: Baby is born on July 1, 2023 and is covered for July and through August 31, 2023. In this instance, the birth month and following month both have 31 calendar days, for a total of 62 days of coverage. DHCS s recommended submission format for Medi DHCS s recommended submission format for Medi- -Cal beneficiaries A newborn can be submitted as a subscriber in Loop 2010BA, with newborn s information but the mother s ID must be submitted in the subscriber loop. Cal beneficiaries: Note: the accepted parent type is dependent on the line of business (see below): CM, MC, ACA CM, MC, ACA: father s ID OR mother's ID is accepted ML ML: only only mother's ID is accepted Line of Business (LOB) Key: Line of Business (LOB) Key: CM = Commercial MC = Medicare ACA = Affordable Care Act ML = Medi-Cal 4 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

NEWBORN SUBMISSION WHEN NO NEWBORN ID IS AVAILABLE Example 1 Example 1: Newborn submitted as a subscriber (DHCS s Recommended Submission Format) subscriber Newborn can be submitted as a subscriber in Loop 2010BA Newborn can be submitted as a subscriber in Loop 2010BA (when newborn does not have eligibility from DOB): The submission will use the newborn s information (last name, first name, DOB, and gender type) and the parent ID (father or mother). The accepted parent type is dependent on the line of business (see below): CM, MC, ACA CM, MC, ACA: father s ID OR mother's ID is accepted ML ML: only only mother's ID is accepted (when newborn does not have eligibility from DOB): 837 claim example: HL*2*1*22*1~ SBR*S**1145A******HM~ NM1*IL*1* Newborn Newborn Last Name N3*100 DOWNTOWN RD~ N4*ELK GROVE*CA*922209999~ DMG*D8*Newborn DOB Newborn DOB*Newborn Gender type CLM*12340*100***13>B>1*Y*A*Y*Y~ LX*1~ DTP*472*D8*Date of Service~ example: Last Name*Newborn Newborn First Name First Name****MI*Subscriber ID (ML- Mother s id Mother s id) )~ Newborn Gender type~ 5 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

NEWBORN SUBMISSION WHEN NO NEWBORN ID IS AVAILABLE Example 2 Example 2: Newborn submitted as a dependent dependent Newborn can be submitted as a dependent (when newborn does not have eligibility from DOB): (when newborn does not have eligibility from DOB): In loop 2010BA, Subscriber can be submitted as a father or a mother depending on the product line: CM, MC, ACA CM, MC, ACA: father s ID OR mother's ID is accepted ML ML: only only mother's ID is accepted In loop 2000C, Patient Information PAT*19 Individual Relationship Segment (child/dependent) In loop 2010CA NM1*QC, submit newborn information in this segment. In some cases, the first name can be submitted under PAT*19 as a BABY and the last name as BOY or GIRL. 837 claim example: HL*2*1*22*1~ SBR*S**1145A******HM~ NM1*IL*1*Subscriber Last Name*Subscriber First Name****MI*Subscriber ID~ (2010BA Loop) NM1*PR*2*HEALTH NET*****PI* 954402957~ HL*3*2*23*0~ PAT*19~(2000C Loop) NM1*QC*1*Newborn Last Name* Newborn First Name ~ (2010CA Loop) N3*100 DOWNTOWN RD~ N4*ELK GROVE*CA*922209999~ DMG*D8*Newborn DOB*Newborn Gender type~ CLM*12340*100***13>B>1*Y*A*Y*Y~ LX*1~ Date of Service~ 6 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

EXAMPLE: NEWBORN SUBMISSION WHEN NEWBORN ID IS AVAILABLE Newborn is billed as a subscriber (when the newborn has eligibility from the date of birth): In loop 2010BA, submit the newborn as the subscriber using the Subscriber Name NM1 segment. Note: this is the standard way to submit an encounter when the subscriber has eligibility and their ID assigned. 837 claim example: HL*2*1*22*1~ SBR*S**1145A******HM~ NM1*IL*1*Newborn Last Name* Newborn First Name****MI* Newborn ID~ (2010BA Loop) N3*100 DOWNTOWN RD~ N4*ELK GROVE*CA*922209999~ DMG*D8* Newborn DOB* Newborn Gender type~ CLM*12340*100***13>B>1*Y*A*Y*Y~ LX*1~ DTP*472*D8*Date of Service~ 7 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

HOW TO SUBMIT MULTIPLE NEWBORN ENCOUNTERS To avoid duplicate encounter rejections for multiple newborns To avoid duplicate encounter rejections for multiple newborns: 1. Multiple newborn encounters can be submitted with one of these unique modifiers* (25, XE, XP, and XU see next slide for definitions) to override DHCS duplicate logic 2. In addition, the encounters can be submitted with a diagnosis code that relates to the type of multiple birth (refer slide 10 for more details) 3. Payors can take specific diagnosis codes and one of these (25, XE, XP, and XU) modifier* combinations to override the duplicate edit (for Medi-Cal, any of these modifiers will override the DHCS duplicate logic; for lines of business other than Medi-Cal, every claim line has to be unique in order to override duplicate logic) 4. Reference the HICE Inbound Encounters Newborn Logic Template available on the HICE Website and the IHA Encounter Data Resource Hub to view the data elements currently in use by various industry organizations for inbound encounters newborn logic, including the California Department of Health Care Services (DHCS) and health plans *Modifiers 25, XE, XP and XU along with the multiple birth diagnosis code(s) (see slide 10), determine that a service is a distinct and separate encounter 8 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

MODIFIER DEFINITIONS Modifier 25 Modifier 25 - used to indicate that a patient's condition required a significant, separately identifiable evaluation and management (E/M) service above and beyond that associated with another procedure or service being reported by the same physician or other qualified health care professional (QHP) on the same date Modifier XE Modifier XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter - only use XE to describe separate encounters on the same date of service Modifier XP Modifier XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner Modifier Modifier XU components of the main service XU Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual 9 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

DIAGNOSIS CODES LIST TO SUBMIT MULTIPLE BIRTH NEWBORNS ICD-10-CM Codes Z00-Z99 Z30-Z3A Liveborn infants according to place of birth and type of delivery Z38 Liveborn infants according to place of birth and type of delivery Z38- Applicable To This category is for use as the principal code on the initial record of a newborn baby. It is to be used for the initial birth record only. It is not to be used on the mother's record. Z38.6 Other multiple liveborn infant, born in hospital Z38.61 Triplet liveborn infant, delivered vaginally Z38.62 Triplet liveborn infant, delivered by cesarean Z38.63 Quadruplet liveborn infant, delivered vaginally Z38.64 Quadruplet liveborn infant, delivered by cesarean Z38.65 Quintuplet liveborn infant, delivered vaginally Z38.66 Quintuplet liveborn infant, delivered by cesarean Z38.68 Other multiple liveborn infant, delivered vaginally Z38.69 Other multiple liveborn infant, delivered by cesarean Z38.7 Other multiple liveborn infant, born outside hospital Z38.8 Other multiple liveborn infant, unspecified as to place of birth Codes Z38 Liveborn infants according to place of birth and type of delivery Z38.0 Single liveborn infant, born in hospital Z38.00 Single liveborn infant, delivered vaginally Z38.01 Single liveborn infant, delivered by cesarean Z38.1 Single liveborn infant, born outside hospital Z38.2 Single liveborn infant, unspecified as to place of birth Z38.3 Twin liveborn infant, born in hospital Z38.30 Twin liveborn infant, delivered vaginally Z38.31 Twin liveborn infant, delivered by cesarean Z38.4 Twin liveborn infant, born outside hospital Z38.5 Twin liveborn infant, unspecified as to place of birth Codes listed as of June 2023. List is available at: https://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z30-Z39/Z38- 10 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

EXAMPLE: MULTIPLE NEWBORNS SUBMITTED IN 837 FORMAT NEWBORN 1 This example is for Medi-Cal / not applicable to other LOBs HL*2*1*22*1~ SBR*S**11XXA******HM~ NM1*IL*1* Newborn Last Name*Newborn First Name****MI*Subscriber ID (ML- Mother s id) ~ N3*100 DOWNTOWN RD~ N4*ELK GROVE*CA*922209999~ DMG*D8*Newborn DOB*Newborn Gender type~ CLM*12340*100***13>B>1*Y*A*Y*Y~ AMT*F5*25~ HI*ABK:Z00110*ABF:Z3861~ =========Diagnosis code NM1*82*1*SMITH*JOHN****XX*1234567890~ LX*1~ SV1*HC:99460*100*UN*1***1~<=======No modifier DTP*472*D8* Date of Service ~ Use of Diagnosis code Z3861 Use of Diagnosis code Z3861 triplet, liveborn infant, delivered vaginally triplet, liveborn infant, delivered vaginally No modifier No modifier 11 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

EXAMPLE: MULTIPLE NEWBORNS SUBMITTED IN 837 FORMAT NEWBORN 2 This example is for Medi-Cal / not applicable to other LOBs HL*2*1*22*1~ SBR*S**11XXA******HM~ NM1*IL*1* Newborn Last Name*Newborn First Name****MI*Subscriber ID (ML- Mother s id) ~ N3*100 DOWNTOWN RD~ N4*ELK GROVE*CA*922209999~ DMG*D8*Newborn DOB*Newborn Gender type~ CLM*12340*100***13>B>1*Y*A*Y*Y~ AMT*F5*25~ HI*ABK:Z00110*ABF:Z3861~ =========Diagnosis code NM1*82*1*SMITH*JOHN****XX*1234567890~ LX*1~ SV1*HC:99460: XE**100*UN*1***1~<=======XE modifier DTP*472*D8* Date of Service ~ Use of Diagnosis code Z3861 Use of Diagnosis code Z3861 triplet, liveborn infant, delivered vaginally triplet, liveborn infant, delivered vaginally Use of modifier XE Use of modifier XE separate encounter, a service that is distinct because it occurred during a separate separate encounter, a service that is distinct because it occurred during a separate encounter encounter 12 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

EXAMPLE: MULTIPLE NEWBORNS SUBMITTED IN 837 FORMAT NEWBORN 3 This example is for Medi-Cal / not applicable to other LOBs HL*2*1*22*1~ SBR*S**11XXA******HM~ NM1*IL*1* Newborn Last Name*Newborn First Name****MI*Subscriber ID (ML- Mother s id) ~ N3*100 DOWNTOWN RD~ N4*ELK GROVE*CA*922209999~ DMG*D8*Newborn DOB*Newborn Gender type~ CLM*12340*100***13>B>1*Y*A*Y*Y~ AMT*F5*25~ HI*ABK:Z00110*ABF:Z3861~ =========Diagnosis code NM1*82*1*SMITH*JOHN****XX*1234567890~ LX*1~ SV1*HC:99460: XE**100*UN*1***1~<=======XE modifier DTP*472*D8* Date of Service ~ Use of Diagnosis code Z3861 Use of Diagnosis code Z3861 triplet, liveborn infant, delivered vaginally triplet, liveborn infant, delivered vaginally Use of modifier XE Use of modifier XE separate encounter, a service that is distinct because it occurred during a separate separate encounter, a service that is distinct because it occurred during a separate encounter encounter 13 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

SOURCES DHCS-PACES Encounter Data Mother-Newborn Encounter Reporting-2.0 Please check with DHCS or your contracted health plan for the latest version of the reporting guidance. 14 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub

HICE RESOURCES HICE Encounters Standardization Team HICE Encounters Standardization Team Documents HICE Team Folders Working Documents: Materials Library Approved HICE Documents - Best Practices and Additional Resources Questions about this document? Contact: admin@iceforhealth.org 15 Prepared as part of IHA s Encounter Data Improvement program. Prepared as part of IHA s Encounter Data Improvement program. Learn more at IHA s Encounter Data Resource Hub