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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 6 Licensed Midwife (LM) : 6.2 Services, Benefits, Limitations, and Prior Authorization : 6.2.3 Prenatal Services

6.2.3
LM providers must include modifier TH with the appropriate evaluation and management procedure code (99201, 99202, 99211, or 99212) for prenatal services.
LM providers are limited to a total of 20 outpatient prenatal care visits, performed in a birthing center, per pregnancy. Normal pregnancies are anticipated to require around 11 visits per pregnancy and high-risk pregnancies are anticipated to require around 20 visits per pregnancy. If more than 20 visits are medically necessary, the provider can appeal with documentation supporting pregnancy complications. The high-risk client’s medical record documentation should reflect the need for increased visits and is subject to retrospective review.
If a client is discharged before delivery, LM providers may submit procedure code 99218, 99219, or 99220 for labor services only. Clinical documentation that clearly demonstrates the level of medical decision-making (i.e., moderate or complex) must be included in the client’s medical record. All medical documentation is subject to retrospective review. Services that are not supported by the medical documentation are subject to recoupment.
Refer to:
Subsection 3, “Obstetric Services,” in the Gynecological and Reproductive Health and Family Planning Services Handbook for billing requirements.

Texas Medicaid & Healthcare Partnership
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