Fact Sheet: Alternative Birth Centers Medi-Cal Fee-for-Service Billing Requirements

While Medi-Cal managed care plans (MCP) are required to offer the same benefit package as Medi-Cal FFS and often utilize Medi-Cal FFS billing codes, some Medi-Cal MCPs may have different utilization management controls and billing policies. As a result, midwives should confirm those policies with each Medi-Cal MCP with whom they are contracted to provide services to Medi-Cal members.  

Facility Fee Eligibility for Alternative Birth Centers

• Alternative Birth Centers (ABCs) (APL 26-005; APL 15-017) are California’s equivalent of freestanding birth centers (FBCs), which are specialty clinics authorized to bill Medi-Cal for obstetrical and delivery services (Alternative Birthing Centers (altern)), as well as for Comprehensive Perinatal Services Program (CPSP).
• Licensed ABCs will use HCPCS Z7516 for the global facility fee, limited to one per pregnancy (6-month period), if the delivery occurs at the ABC.
• If a patient begins their labor at the ABC but then is subsequently transferred to a hospital for delivery, the licensed ABC can use HCPCS Z7516 with modifier 52 and be reimbursed a proportion of the overall facility fee (Alternative Birthing Centers (altern)).
• A facility fee (Z7516) can also be billed directly under the Licensed Midwife (LM) or Certified Nurse Midwife (CNM) who is the legal owner of the ABC, for professional services completed by a LM or CNM at the ABC.

Newborn Billing

• Newborn services are billed separately from the mother’s delivery.
• For example, an LM/CNM can bill for the initial care, per day, for evaluation and management (E&M) of a normal newborn infant using 99460, and 99463 for the initial care, per day, for the E&M of a normal newborn infant admitted and discharged on the same date.
• The LM/CNM could bill using 99461 for the initial newborn care performed in the home or other setting, outside hospital or licensed ABC.
• A separate facility fee for the newborn cannot be billed, in addition to the facility fee billed for the mother. HCPCS Z7516 applies only to the mother’s delivery and facility use.

Home Birth Delivery with Newborn Assessment Example

• When delivery occurs at home with a midwife (LM/CNM), the midwife can bill for the vaginal delivery using 59409 but cannot bill for the facility fee (Z7516). If the midwife also completed the newborn assessment after the delivery, then 99461 could be used to bill. 

Delivery in Alternative Birth Center who has Not Undergone the CDPH Licensing Process with Newborn Assessment Example

• When a midwife delivers at a non-licensed birth center (i.e. one that has not undergone the CDPH licensing process), the practitioner fees can be billed for the delivery using 59409 and the newborn assessment after birth can be billed using 99461. In addition, a facility fee may also be billed using Z7516 by the LM/CNM who is the legal owner of the ABC.

Licensed Alternative Birth Center Delivery with Newborn Assessment Example

• When a midwife delivers vaginally at a licensed ABC, the midwife can bill for the vaginal delivery using 59409, as well as the facility fee Z7516. The midwife completes the initial newborn assessment after birth at the ABC and bills using 99463 because the member and newborn leave within 24-hours of delivery.