5160-4-10 Pregnancy related services.

(A) "Pregnancy related services" identified in paragraphs (B) to (F) of this rule are optional preventive health services available to all medicaid-eligible women. These services are intended to promote positive birth outcomes by supplementing regular obstetrical care. Services identified in paragraphs (G) and (H) of this rule are covered services for women who need therapeutic intervention to prevent poor birth outcome.

(1) Pregnancy related services may be delivered by physicians, hospitals, clinics, rural health clinics, outpatient health facilities, federally qualified health centers, and advanced practice nurses who are eligible medicaid providers. When provided, these services must be billed in accordance with the specific billing requirements and procedures for the provider type of the rendering provider as specified in Chapter 5101:3 of the Administrative Code.

(2) These services may also be delivered, but not billed directly, by health care professionals (e.g., dietitians, social workers) who are not eligible medicaid providers, if the services provided are within the professional's scope of practice and the professional is employed by or under contract with an eligible medicaid provider.

(3) Pregnancy related services may be provided in a patient's home or at the provider's practice site.

(4) When billing for pregnancy related services listed in this rule with the exception of the predelivery visit to a pediatrician or other primary care provider, follow the billing instructions listed in this paragraph:

(a) Bill the appropriate code(s) specified in this rule with the modifier "TH" to indicate that obstetrical services, prenatal or post-partum, were provided.

(b) Bill the appropriate diagnosis code to indicate that the diagnosis is for antepartum care- either V22, V23, or V28.

(B) Care coordination

(1) A provider may be reimbursed a monthly care coordination fee (once every four weeks) if the provider furnishes all the following services, as appropriate, to the patient:

(a) Performs a social/psycho social assessment identifying factors which may affect the patient's ability to follow prescribed care and necessary social services.

(b) Develops a written individual care plan which includes a timetable for the delivery of medical services as prescribed by the physician or nurse midwife and any recommended social services.

(c) Assists the physician and patient in the scheduling and coordination of services identified in the care plan;

(d) Reviews the care plan at least once every four weeks and updates the plan to reflect any revisions;

(e) Provides a copy of the care plan to the patient;

(f) Makes necessary referrals for nonmedical services, including but not limited to:

(i) County department of job and family services for needed transportation, casework, or social services (e.g., food, clothing, shelter, etc.);

(ii) Special supplemental food program for women, infants, and children (WIC); and

(iii) Other social service agencies as needed (e.g., child support, children services, mental health, drug and alcohol);

(g) Makes telephone contact or provides a written reminder for the patient prior to all appointments;

(h) Telephones the patient or sends a written notice of any missed appointments and makes arrangements with the patient to reschedule the appointment. Requests assistance from the at-risk pregnancy coordinator at the patient's residential county department of job and family services when the patient is noncompliant in keeping appointments (e.g., misses back-to-back appointments).

(2) For reimbursement, the provider must bill code H1002. This code may be billed on the initial date of service and once every twenty-eight days thereafter.

(C) Group pre-natal at-risk education

(1) Group education classes on a variety of topics relating to pregnancy, birth, childcare, nutrition, family and support systems are covered on a per class basis. (E.g., Lamaze or other childbirth classes would be considered a covered group education service).

(2) Group education may be a single class covering a single topic or multiple topics or it may be a series of classes covering a single topic or multiple topics.

(3) Group education classes must consist of a face-to-face presentation by a medical professional in a group of no more than twelve patients (not including partners/coaches).

(4) For reimbursement, the provider must bill the appropriate code listed in this paragraph to indicate the type of group session attended by the recipient. The unit of service for each session (one or more classes) is limited to one per pregnancy. The following group education sessions for pregnancy session are covered by medicaid effective with services provided on and after the effective date of this rule:

(a) For childbirth preparation/Lamaze classes, non-physician provider, per session, bill S9436.

(b) For childbirth refresher classes, non-physician provider, per session, bill S9437;

(c) For nutrition classes provided to pregnant women by a non-physician provider, per session, bill S9452.

(d) For baby parenting classes provided to pregnant women by a non-physician provider, per session, bill S9444; and

(e) For infant safety classes provided to pregnant women by a non-physician provider, per session, bill S9447.

(D) Individual counseling and education

(1) When the counseling and educational services exceed those normally provided during a prenatal visit, focus primarily on the specific needs of the individual, and involve an individual face-to-face encounter of approximately fifteen minutes or more, the provider may be paid for an individual counseling and education service in addition to the antepartum visit.

(2) For reimbursement, the provider must bill code H1003.

(E) Predelivery visit to a pediatrician or other primary care provider

(1) To encourage families to obtain early and continuous well-child and primary care for their newborn, the department covers pre-delivery visits to a pediatrician or other primary care physicians. The purpose of this service is to give the mother (or family) the opportunity to select, and establish a patient-physician relationship with, a physician for the care of her (their) infant.

(2) For reimbursement, the provider must bill the most appropriate evaluation and management (visit) code.

(F) High-risk patient monitoring/antepartum management

(1) A provider may be reimbursed for high-risk patient monitoringnow known as antepartum management provided on a weekly basis to a patient who has been determined by the provider to be at-risk of a preterm birth.

(2) "High-risk patient monitoring"/antepartum management is a service which includes counseling and educational services associated with identifying and reducing the risks of a preterm labor, telephone or face-to-face contact with the patient a minimum of three times a week to identify signs of preterm labor and accessibility of the provider to the patient in the event the patient begins to show signs of preterm labor.

(3) High-risk patient monitoring/antepartum management must be provided by a health care professional who is qualified to identify the signs of preterm labor and is employed by or under contract with an eligible provider of physician services.

(4) For reimbursement, the provider must bill code H1001 for antepartum management.

(G) Nutrition intervention

(1) Basic nutrition education and counseling services are considered a part of routine antepartum care.

(2) "Nutrition intervention" is a service provided to a pregnant or postpartum woman who has a medical need for a therapeutic diet. Nutrition intervention includes the following:

(a) Specialized nutrition counseling and education as it relates to the medically diagnosed problem or high-risk factor;

(b) Development of an individual diet plan, including a therapeutic diet calculation;

(c) Teaching of therapeutic diet or other nutritional modifications of diet, and the provision of sample meal plans and patterns;

(d) Monitoring the results of the nutrition intervention and making any necessary changes in the dietary plan.

(3) Nutrition intervention may be delivered by a physician or a dietitian who is licensed by the state of Ohio or who has equivalent qualifications if practicing outside the state.

(4) Dietitians delivering nutrition intervention may not bill for the service directly but must be under contract with or employed by an eligible medicaid provider.

(5) For reimbursement, the provider must bill code, S9470 for medical nutrition therapy counseling for pregnant women provided by a dietician employed by or under contract with an eligible medicaid provider. For nutrition therapy provided by a physician, bill the appropriate evaluation and management code with diagnosis code V22, V23, or V28. In both cases, the "TH" modifier must be billed to reflect that the nutrition intervention is for prenatal at-risk educational purposes and the appropriate pregnancy diagnosis code must be billed.

(6) For group nutrition classes which are described in paragraph (C) of this rule, bill the code S9452.

(H) Prenatal risk assessment

(1) Providers may receive reimbursement for a prenatal risk assessment if the provisions described in paragraph (C) of rule 5101:3-4-08 of the Administrative Code are met.

(2) To receive reimbursement for a prenatal risk assessment, providers must bill code H1000.

(I) Reimbursement

(1) Payment for pregnancy related services provided by providers of physician services in an office or fee-for-service clinic setting will be the provider's billed charge or the payment amount listed in appendix DD of rule 5101:3-1-60 of the Administrative Code.

(2) When pregnancy services are provided by the hospital to hospital outpatients, the hospital will be reimbursed the rates listed in appendix F of rule 5101:3-2-21 of the Administrative Code.

Eff 4-1-88; 5-15-89; 2-14-92; 1-1-01; 7-1-03
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01, 5111.02
R.C. 119.032 review dates: 10/08/2002 and 07/01/2008