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SECTION 9 MATERNITY CARE AND DELIVERY - page 4 / 5

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Section 9

Maternity Care and Delivery

January 2013

No, MO HealthNet may not be billed for the start up of a pitocin drip. Not only is this procedure included in the global OB billing, it is also included in the delivery code if not billing global.

Can obstetrical ultrasounds be billed separately?

Yes, you may bill for ultrasounds when the ultrasounds are medically necessary. Obstetrical ultrasounds are limited to three per calendar year per participant. If more than three are performed in one calendar year, the additional ultrasounds must be reasonable and necessary based on the medical indication(s). The medical necessity must also be documented in the patient's medical record. Only one ultrasound is allowed per day. If it is medically necessary to perform a repeat ultrasound on the same day, refer to the CPT for follow-up or repeat procedures.

If the MO HealthNet patient has received care for her pregnancy by a provider on three different occasions, can another provider still bill global if they have met all the global guidelines?

No, the participant is allowed two visits to a provider to establish the pregnancy and obtain a referral. If more than two visits to another provider have been reimbursed by MO HealthNet, the provider of ongoing care must bill out all services separately, i.e., office visits, each urinalysis, hospital visits, delivery, etc.

WILL YOUR PATIENT BE IN A MANAGED CARE HEALTH PLAN?

Depending on the area of the state, it is quite possible many of your patients may be required to enroll in a managed care health plan and choose a primary care provider. Once a patient is enrolled in a managed care health plan, payment for covered services becomes the responsibility of the health plan. Providers are encouraged to contact health plans to become enrolled as a managed care provider with the plans.

If a patient becomes enrolled in a managed care health plan in her third trimester of pregnancy, she may elect to continue to receive her obstetrical services from an out-of- plan provider. The out-of-plan provider must contact the appropriate health plan for instructions. If the out-of-plan provider only has admitting privileges in an out-of-plan hospital, the health plan is obligated to negotiate with the hospital on an agreeable reimbursement schedule.

When a patient receives more than two prenatal visits in a fee-for-service setting and transitions into a managed care health plan and changes providers, neither provider may bill for a global OB service. In this situation, both providers must bill for each date of service using the appropriate CPT code.

When the obstetrical care begins as fee-for-service and continues with the same provider into a managed care health plan, the provider must bill for date specific services for each program (MO HealthNet and the managed care health plan). The provider cannot submit a claim for global OB care to either program.

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