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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 3 Obstetric Services : 3.1 *Services, Benefits, Limitations, and Prior Authorization : 3.1.13 Antenatal and Postnatal Care Visits

The following procedure codes may be submitted for antenatal and postnatal care visits:
Texas Medicaid reimburses prenatal care, deliveries, and postpartum care as individual procedures.
Prenatal and postpartum care visits billed in an inpatient hospital (POS 3), will be 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.
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 one postpartum care visit after discharge from the hospital.
Licensed midwives (LMs) are limited to 20 outpatient antepartum care visits per pregnancy to be performed in a birthing center; postpartum visits are not separately reimbursed. 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.
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 another physician of the same specialty who belongs to the same group, within the last three years (36 months).
When billing for prenatal services, use modifier TH with the appropriate E/M procedure code to the highest level of specificity.
LMs are not reimbursed for postpartum visits.
One postpartum care procedure code may be reimbursed per pregnancy. The claim for the postpartum visit may be submitted with either procedure code 59430 or with a delivery procedure code (59410, 59515, 59614, or 59622) that includes postpartum care. The reimbursement amount for the submitted procedure code covers all postpartum care per pregnancy regardless of the number of postpartum visits provided.
Any other E/M office visit will not be reimbursed when billed 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 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.

Texas Medicaid & Healthcare Partnership
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