TMPPM 2011 > Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook > Physician > Services/Benefits, Limitations, and Prior Authorization > Obstetrics and Prenatal Care

8.2.44 Obstetrics and Prenatal Care

Medicaid reimburses prenatal care, deliveries, and postpartum care as individual services. Providers may choose one of the following options for billing maternity services:

•Providers may itemize each service individually on one claim form and file at the time of delivery. The filing deadline is applied to the date of delivery.

•Providers may itemize each service individually and submit claims as the services are rendered. The filing deadline is applied to each individual date of service.

Providers who only provide prenatal care and choose to submit prenatal visit charges on one claim form have the filing deadline applied to the estimated date of confinement (EDC) that must be stated in Block 24D of the CMS-1500 claim form.

Laboratory (including pregnancy tests) and radiology services provided during pregnancy must be billed separately and claims must be received by TMHP within 95 days of the date of service.

When billing for prenatal services, use modifier TH with the appropriate evaluation and management procedure code to the highest level of specificity. Failure to use modifier TH may result in recoupment of payment rendered.

Providers must bill the most appropriate new or established patient prenatal or postnatal visit procedure code. New patient codes may be used when the client has not received any professional services from the same physician or a physician of the same specialty who belongs to the same group, within the past three years.

Physicians (obstetricians, family practice physicians, and maternal-fetal medicine specialists), CNMs, and maternity service clinics (MSCs) are limited to 20 prenatal care visits per pregnancy and two postpartum care visits after discharge from the hospital. Routine pregnancies are anticipated to require around 11 visits per pregnancy, and high-risk pregnancies are anticipated to require around 20 visits per pregnancy.

More frequent visits may be necessary for high-risk pregnancies. High-risk obstetrical visits are not limited to 20 visits per pregnancy. The provider can appeal with documentation supporting a complication of pregnancy. Documentation reflecting the need for increased visits must be maintained in the physician's files and is subject to retrospective review.

Prenatal and postpartum care visits billed in an inpatient hospital (POS 3) are denied as part of another procedure when billed within the three days before delivery or the six weeks after delivery. The inpatient intrapartum and postpartum care are included in the fee for the delivery or Cesarean section and should not be billed separately.

Postpartum care provided after discharge must be billed using procedure code 59430. A maximum of two postpartum visits are allowed.

Any other E/M office visit will not be reimbursed when billed with the same date of service, by the same provider, as any antenatal or postpartum office visit. Modifier 25 may be used to identify a significant, separately identifiable E/M service performed by the same physician on the same date of service as the procedure or other service. Documentation that supports the provision of a significant, separately-identifiable E/M service must be maintained in the client's medical record and made available to Texas Medicaid upon request.

Delivering physicians who perform regional anesthesia or nerve block do not receive additional reimbursement because these charges are included in the reimbursement for the delivery except as outlined under subsection 8.2.6.3, "Anesthesia for Labor and Delivery" in this handbook. Medicaid may reimburse only one delivery or Cesarean section procedure code per client in a seven-month period; reimbursement includes multiple births.

Procedure code 99140 is not considered for reimbursement when submitted with diagnosis code 650 for a normal delivery or with diagnosis code 66970 or 66971 for a Cesarean delivery when one of these diagnosis codes is documented on the claim as the referenced diagnosis. The referenced diagnosis must indicate the complicating condition. An emergency is defined as a situation when delay in treatment of the client poses a significant health threat to a client's life, bodily organ, or body part.

Hospital admissions resulting from conditions or comorbidities complicating labor should be billed using the appropriate E/M procedure codes. These codes are not subject to the three-day pre-care period but are not payable on the date of delivery or the following six-week post-care period.

Refer to: Subsection 8.2.6, "Anesthesia" in this handbook for complete information about anesthesia for obstetrical procedures.