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SECTION 9 MATERNITY CARE AND DELIVERY - page 5 / 5

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Section 9

Maternity Care and Delivery

January 2013

TEMPORARY MO HealthNet DURING PREGNANCY (TEMP), MEDICAL ELIGIBILITY (ME) CODE 58 OR 59

The purpose of the Temporary MO HealthNet During Pregnancy (TEMP) Program is to provide pregnant women with access to prenatal care while they await the formal determination of MO HealthNet eligibility.

TEMP services for pregnant women are limited to ambulatory physician, clinic, nurse- midwife, diagnostic laboratory, x-ray, pharmacy, and outpatient hospital services. Services other than those listed above may be reimbursed if a Certificate of Medical Necessity is submitted with the claim and it testifies that the pregnancy would have been adversely affected without the service.

The diagnosis on the claim form must be a pregnancy/prenatal diagnosis (V22.0 through V23.9 or V28 through V28.9). Nurse midwives must use diagnosis codes V22.0 through V22.2 or V28 through V28.9.

Inpatient hospital services and deliveries performed either inpatient or outpatient are not covered under the TEMP program. Other non-covered services include postpartum care; contraceptive management; D&C; treatment of spontaneous, missed abortions or other abortions.

Infants born to mothers who are eligible under the TEMP Program are not automatically eligible under this program.

ABORTIONS AND MISCARRIAGES

MO HealthNet does not cover elective abortion services.

Any claim with a diagnosis of miscarriage, or missed or spontaneous abortion, diagnosis codes 632, 634.00-634.92, 635.00-635.92, 636.00-636.92, 638.0-638.9 and 639.00- 639.9, must be submitted on a paper CMS-1500 claim form with all appropriate documentation attached. The documentation must include, at the minimum, the operative report, an ultrasound, the pathology report and the admit and discharge summary, to show that this was not an elective abortion. If no ultrasound was performed, the reason for not performing it must be clearly documented in the patient’s medical record.

The above information is required also when submitting a claim with one of the following CPT codes: 59200, 59812, 59821, or 59830.

CPT codes 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, and 59866 also require a completed Certificate of Medical Necessity for Abortion form in addition to the previously noted documents.

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