5160-4-08 Covered obstetrical services.

(A) Providers of obstetrical services must bill each antepartum visit, separately. The department does not recognize the codes for "global obstetrical care" which bundle these services under a single procedure code. The department does recognize the code for delivery and postpartum services which may be billed using a single procedure code when the services are provided by the same provider.

(B) The following obstetrical services are covered as detailed below:

(1) Prenatal risk assessment;

(2) All antepartum care including pregnancy related services;

(3) Delivery; and

(4) Postpartum care.

(C) Prenatal risk assessment (PRA)

(1) The "Prenatal Risk Assessment (PRA)" form, JFS 03535, is a checklist of medical and social factors which is used as a guideline to determine when a patient is at risk of a preterm birth or poor pregnancy outcome.

(2) The PRA form must be completed on each obstetrical patient during the initial antepartum visit in order to bill for the prenatal at-risk assessment code. A copy of the PRA form should be placed in the patient's record to serve as documentation that the service was provided.

(3) Providers must submit a copy of the PRA form to the patient's residential county department of job and family services since the county staff can assist patients obtaining needed services.

(4) When significant risk factors that were not noted on the original PRA form are identified during the course of the pregnancy, providers are encouraged to complete another risk assessment form and to send a copy to the county department of job and family services.

(5) Providers may receive reimbursement for completing the PRA form by billing the code for prenatal risk assessment specified in rule 5101:3-4-10 of the Administrative Code.

(D) Antepartum care

(1) Antepartum visits

(a) The antepartum visit is inclusive of:

(i) Instruction, education and counseling on a variety of topics related to pregnancy, nutrition, baby-care and family;

(ii) Routine urinalysis screening tests (dipstick) to detect the presence of sugar or protein;

(iii) A physical examination which includes recording of weight, blood pressure, and fetal heart tones or similar routine services;

(iv) Coordination of the patient's medical care including at a minimum a planned hospital delivery, arrangements for medical care and/or consultation (by telephone) in case of an emergency, and referrals to appropriate medical services (i.e., ultrasounds, etc.).

(b) Medical care coordination, education and counseling services provided as part of the antepartum visit should be consistent with those services generally required for all obstetrical patients. When the care coordination and/or counseling and educational services provided to an individual are more extensive than the services routinely provided to obstetrical patients, a provider may be compensated for these services by billing the pregnancy related services detailed in rule 5101:3-4-10 of the Administrative Code.

(c) Antepartum visits must be billed to the department on a per-visit basis using the evaluation and management (office visit) code appropriate for the type of visit documented in the patient's record. When the antepartum visit is billed, specify a diagnosis to signify pregnancy such as V22 for supervision of normal pregnancy, V23 for supervision of a high-risk pregnancy, or V28 for antenatal screening. Bill the code modified by the "TH" modifier to signify "obstetrical services, prenatal or post-partum".

(2) Additional services

(a) In addition to the antepartum visit, reimbursement is available for the following services provided during the antepartum and postpartum periods:

(i) Pregnancy related services which are described in rule 5101:3-4-10 of the Administrative Code.

(ii) All obstetrical-related radiology and laboratory procedures (with the exception of urinalysis screening tests) actually performed in the physician's office;

(iii) All obstetrical diagnostic procedures identified in standard code sets; and

(iv) All covered medical services provided in addition to the antepartum visit.

(b) The services listed in paragraph (D)(2)(a) of this rule may be provided independently on any date of service, or they may occur sequentially on the same date as the antepartum visit or any other covered service.

(E) Delivery and postpartum care.

(1) "Delivery services" include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without forceps and/or episiotomy), or Cesarean section delivery.

(2) "Postpartum care" includes hospital and office visits for routine, uncomplicated care following a vaginal or Cesarean section delivery.

(3) Under paragraph (E) of this rule, "same provider" means the rendering provider or any member of the same group practice.

(4) The following codes should be billed:

(a) For delivery and postpartum services provided to patients for which a vaginal or Cesarean delivery after a previous Cesarean delivery (VBAC) was not attempted.

59409 For a vaginal delivery when outpatient postpartum care is provided by another provider or provider group.

59410 For a vaginal delivery when outpatient postpartum care is provided by the same provider or provider group.

59514 For a Cesarean section when outpatient postpartum care is provided by another provider or provider group.

59515 For a Cesarean section when outpatient postpartum care is provided by the same provider or provider group.

(b) For delivery and postpartum services provided on or after January 1, 1996 to patients for which a VBAC was attempted.

59612 For a vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or forceps) when outpatient postpartum care is provided by another provider or provider group.

59614 For a vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or forceps) when outpatient postpartum care is provided by the same provider or provider group.

59620 Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery when outpatient postpartum care is provided by another provider or provider group.

59622 Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery when outpatient postpartum care is provided by the same provider or provider group.

(c) Postpartum care when performed as a separate procedure.

59430 For postpartum care only.

(5) For the reimbursement of codes 59410, 59430, 59515, 59614 or 59622, the provider must, at a minimum, render an evaluation and management service four to six weeks post-delivery.

(6) Under the medicaid program, the provision of postpartum care rendered prior to discharge from the inpatient hospital, outpatient hospital or birthing center (i.e. the delivering institution) is considered incidental to the delivery services and/or postpartum service and should not be a factor when selecting the delivery only codes or the delivery codes bundled with the postpartum care services.

(a) For the reimbursement of the delivery only codes the provider or provider group must render, at a minimum, the delivery service;

(b) For reimbursement of the delivery and postpartum care codes, the provider or provider group practice must render, at a minimum, bot the delivery and at least one evaluation and management service four to six weeks post-delivery;

(c) For the reimbursement of the postpartum care only code, the provider or provider group practice must render, at a minimum, at least one evaluation and management service four to six weeks post surgery.

(7) Additional reimbursement will not be recognized for the complexity of the delivery, for multiple births, or for two physicians performing the same vaginal delivery.

(8) Reimbursement is available for inpatient and outpatient evaluation and management services provided for post-delivery complications or services unrelated to the delivery in accordance with paragraph (M)(3) of rule 5101:3-4-06 of the Administrative Code.

(9) Services of an assistant-at-surgery during a Cesarean delivery are covered in accordance with paragraph (G) of rule 5101:3-4-22 of the Administrative Code.

(10) Services of a pediatrician in attendance at a delivery of a high risk newborn or a Cesarean section are covered in accordance with rule 5101:3-4-06 of the Administrative Code.

(11) All pregnancy related services are covered services during the postpartum period with the exception of high-risk patient monitoring and the predelivery visit.

(F) Transportation services for pregnant women to medicaid covered services will be provided by the patient's residential county department of job and family services, if it is requested by the provider, the recipient or other person acting on the recipient's behalf.

Eff 4-7-77; 12-21-77; 12-30-77; 1-8-79; 2-1-80; 4-1-88; 9-1-89; 5-1-90; 2-14-92 (Emer.); 5-14-92; 12-30-93 (Emer.); 3-31-94; 3-30-95; 12-29-95 (Emer.); 3-21-96; 5-9-96; 7-1-03
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.02
R.C. 119.032 review dates: 10/08/2002 and 07/01/2008