QUEST Integration – Prenatal Visit – Initial and Follow Up Visit after Delivery

Original Effective Date:

01/01/2000

Current Effective Date:

04/01/2019

HMSA’s Plan for QUEST Integration Members will pay for the initial prenatal visit and routine follow up visit after delivery outside the global fee for maternity services. HMSA defines the initial prenatal visit as the visit during which the physician or midwife initiates prenatal care, counsels the patient about risk factors and self-care, determines the patient’s due date and establishes a tentative schedule of future visits. Appropriate lab testing (e.g., obstetric panel) also may be ordered at this visit.

Physicians and midwives are encouraged to bill separately for the initial visit and routine follow up visit after delivery to receive an overall increase in the payment for the total maternity care. In addition, QUEST Integration will be able to identify pregnant members early in their pregnancy so that educational information and outreach services can help her enjoy an uneventful pregnancy and healthy newborn infant.

With the exception of the initial prenatal visit and follow up visit after delivery, delivery and postpartum care will continue to be included in the global fee for maternity services. For more information, see QUEST Integration – Maternity – Global Billing.

Guidelines

Only one prenatal visit per pregnancy is payable. If the patient’s maternity care is transferred after the initial visit takes place, the second provider may not bill for an initial prenatal visit.

If the patient started prenatal care before becoming eligible for QUEST Integration, the first prenatal visit after becoming eligible for QUEST Integration may be billed as the initial visit.

Claims Filing Instructions

Initial Prenatal Visit

When completing a claim for the initial prenatal visit, please:

• Complete Block 14 of the CMS 1500 claim form. This block should show the date of the patient’s last menstrual period (LMP).
• Bill an appropriate level of new patient or established patient office visit.
• Indicate a diagnosis of ICD-10-CM: Z34.00 – Z34.93 (supervision of normal pregnancy) or ICD-10-CM: O09.00 – O09.93 (supervision of high-risk pregnancy).
• Do not bill a dipstick urinalysis (CPT 81000) separately; this test is considered an integral part of a prenatal visit. However, other diagnostic tests may be billed as appropriate.
• Do not bill subsequent prenatal visits separately; these visits are included in the global fee for maternity services.

Initial Prenatal Visit Claim Example

An obstetrician is seeing an established patient for an initial prenatal visit. This is the patient’s first pregnancy. She reports mild hyperemesis gravidarum in addition to the usual symptoms of pregnancy. The claim should be completed as follows:

Routine Follow-up Visit after Delivery

When completing a claim for the routine follow up visit following delivery, please:

• Complete Block 14 of the CMS 1500 claim form. This block should show the date of the patient’s last menstrual period (LMP).
• Bill an appropriate level of new patient or established patient office visit.
• Indicate a diagnosis of ICD-10-CM: Z39.1 (Encounter for routine postpartum follow-up) or Z39.2 (Encounter for care and examination for lactating mother) as applicable.

Routine Follow-Up Visit after Delivery Claim Example

An obstetrician is seeing an established patient for a follow-up visit 7 to 84 days after delivery. The patient has no unusual symptoms. The claim should be completed as follows:

Revision History