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Section 9

Maternity Care and Delivery

January 2013

SECTION 9 MATERNITY CARE AND DELIVERY

GLOBAL POLICIES

The global prenatal/delivery/postpartum fee is reimbursable when one physician or physician group practice provides all the patient’s obstetric care. For this purpose, a physician group is defined as a clinic or an obstetric clinic where there is one patient record and each physician/nurse practitioner/nurse midwife seeing that patient has access to the same patient record and makes entries into the record as services occur. A primary care physician is responsible for overseeing patient care during the patient’s pregnancy, delivery, and postpartum care. The clinic may elect to bill globally for all prenatal, delivery, and postpartum care services provided with the clinic, using the primary care physician’s individual National Provider Identifier (NPI) as the performing provider.

Global prenatal care includes all prenatal visits performed at medically appropriate intervals up to the date of delivery, routine urinalysis testing during the prenatal period, care for pregnancy related conditions (e.g. nausea, vomiting, cystitis, vaginitis), and the completion of the Risk Appraisal for Pregnant Women form. Only one prenatal care code, 59425 (four-six visits) or 59426 (seven or more visits), may be billed per pregnancy. The date of the delivery is the date of service to be used when billing the global prenatal codes. If a provider does more than three visits but the participant goes to another provider for the rest of her pregnancy, all visits must be billed using the appropriate office visit procedure codes.

Billing for global services cannot be done until the date of delivery.

EXEMPTED VISITS/CONSULTATIONS A total of two visits may be reimbursed by MO HealthNet to the initial provider (who is not the provider of ongoing care) to establish a pregnancy, perform an initial examination, and make a referral to a second provider. For example, many participants utilize the services of a local health agency to establish their pregnancy which then refers them elsewhere for continuing care for their pregnancy. Therefore, if the participant sees another provider for no more than two visits for her pregnancy, the provider of ongoing care is allowed to bill global.

In addition, two consultations may be reimbursed by MO HealthNet to another provider. The referring provider may still bill global.

RISK APPRAISAL - CASE MANAGEMENT As part of the global prenatal/delivery requirements, providers must complete the Risk Appraisal for Pregnant Women form. No additional reimbursement will be paid for the completion of the form. Any eligible woman who meets any of the risk factors listed on the form is eligible for case management for pregnant women services and should be referred to a MO HealthNet enrolled participating case management provider.

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