Product Lines:
EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31
 
Description:
The percentage of live birth deliveries on or between October 8 of the year prior to the measurement period and October 7 of the measurement period. For these persons, the measure assesses the following facets of prenatal and postpartum care:

• Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit in the first trimester on or before the enrollment start date or within 42 days of enrollment in the organization.
• Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery.

Provider Specialty: PCP, OB/GYN, Prenatal Care Provider 

Stratifications:
Report stratification by race and ethnicity.

Measure Reporting:
Population Health Incentive Program (PHIP).
HealthChoice Performance Measure reporting for Priority Partners. 

Data Collection:

• Administrative.
• Hybrid.
• Supplemental.

Initial Population:

• Measure Item Count: Episode.
• Age: None.
• Benefits: Medical.
• Continuous Enrollment: 43 days prior to delivery through 60 days after delivery.
• Allowable Gap: None.

Definition: 
First trimester: 280–176 days prior to delivery (or estimated delivery date [EDD]).

Denominator:
Deliveries.
Live birth deliveries in any setting on or between October 8 of the year prior to the measurement period and October 7 of the measurement period.

Note: 

• The initial population for this measure is based on deliveries, not on persons; therefore, it is possible for denominator to include multiple deliveries for the same person; only one per 180-day period.
• Criteria for identifying prenatal care for persons who were not enrolled during the first trimester allow more flexibility than criteria for persons who were enrolled. 
  
  • For persons who were enrolled at least 219 days before delivery, the organization has sufficient opportunity to provide prenatal care by the end of the first trimester. 
  • For persons who were not enrolled at least 219 days before delivery, the organization has sufficient opportunity to provide prenatal care within 42 days after enrollment. 

Numerator:
Numerator 1: Timeliness of prenatal care.
A prenatal visit during the required time frame. 

• Persons who were continuously enrolled (with no gaps) from at least 219 days before delivery (or EDD) through 60 days after delivery. These persons must have a prenatal visit during the first trimester. 
• Persons who were not continuously enrolled from at least 219 days before delivery (or EDD) through 60 days after delivery. These persons must have a prenatal visit any time during the period that begins 280 days prior to delivery and ends 42 days after the enrollment start date. 

A prenatal visit where the practitioner type is an OB/GYN or other prenatal care practitioner or PCP: 

• A bundled service (Prenatal Bundled Services Value Set) where the organization can identify the date when prenatal care was initiated (because bundled service codes are used on the date of delivery, these codes may be used only if the claim form indicates when prenatal care was initiated).  
• A visit for prenatal care (Stand Alone Prenatal Visits Value Set). 
• A prenatal visit (Prenatal Visits Value Set) with a pregnancy-related diagnosis code (Pregnancy Diagnosis Value Set).

Numerator 2: Postpartum care.
A postpartum visit on or between 7 and 84 days after delivery. Any of the following meet criteria: 

• A postpartum visit (Postpartum Care Value Set).
• An encounter for postpartum care (Encounter for Postpartum Care Value Set).  
• Cervical cytology (Cervical Cytology Lab Test Value Set; Cervical Cytology Result or Finding Value Set). 
• A bundled service (Postpartum Bundled Services Value Set) where the organization can identify the date when postpartum care was rendered (because bundled service codes are used on the date of delivery, not on the date of the postpartum visit, these codes may be used only if the claim form indicates when postpartum care was rendered).

Note:

• The practitioner requirement only applies to the Hybrid Specification. The organization is not required to identify practitioner type in administrative data.
• A Pap test does not count as a prenatal care visit for the administrative and hybrid specification of the Timeliness of Prenatal Care rate but is acceptable for the Postpartum Care rate as evidence of a pelvic exam. A colposcopy alone is not numerator compliant for either rate. 
• Services that occur over multiple visits count toward this measure if all services are within the time frame established in the measure. Ultrasound and lab results alone are not considered a visit; they must be combined with an office visit with an appropriate practitioner in order to count for this measure.
• The intent is to assess whether prenatal and preventive care was rendered on a routine, outpatient basis rather than assessing treatment for emergent events.
• Services provided during a telephone visit, e-visit or virtual check-in are acceptable for prenatal and postpartum care.
• Birth is considered a live birth if delivered twin and one was stillborn.

Best Practice and Measure Tips

• The system uses the delivery date to calculate the prenatal timeframe and assumes a full-term pregnancy. Members who deliver early may not be compliant and may require the EDD to be updated based on an EDD in an ultrasound report. LMP cannot be used to adjust the EDD.  
• Provide education to members on importance of prenatal and postpartum care for them and their baby.  
• Assess all members for history of or current substance abuse or mental health concerns.
• Incorporate depression screenings at all prenatal and postpartum appointments and ensure prompt intervention and referrals for positive results.
• Follow members closely who have or had a substance abuse or mental health diagnosis. Initiate appropriate referrals and ensure member follow-up with any referrals.
• Identify potential barriers to receiving care when pregnancy is confirmed. Discuss with members ways barriers can be overcome.
• Ensure members are aware of available resources to overcome barriers and any incentives for care.
• Identify members seen in ER with a diagnosis of pregnancy and initiate follow-up.
• Assess members for gaps in recommended pregnancy immunizations. Provide education on importance of being up to date with immunizations.
• For members who do not show or schedule appointments, attempt to engage in a telephone or video visit to close gap.
• Before discharging member from the hospital stay, look at the member’s schedule history for no show or reschedule appointment and if member seems reluctant to schedule an appointment or you suspect they will not show, schedule a telephone or video visit.
• Maintain available appointments for member to be seen during their first trimester or postpartum period.
• When scheduling Postpartum visit, use the discharge day and schedule the member after the 6th day from discharge which begins the postpartum period for the measure (within 7-84 days postpartum).

JHHP Maternity Care Package Codes Guidelines:   

• JHHP Obstetrical Services (EHP/USFHP) Reimbursement Policy RPC.029 requires providers to use CPT-II codes on their claim forms as a “no charge” line item to identify prenatal services and postpartum visit when billing global obstetric (maternity care) package code(s). This requirement ensures accurate capture of HEDIS data measures.
  • When submitting claim for an initial pregnancy diagnosis visit (e.g., urine test, ultrasound), always include CPT-CAT-II 0500F or 0501F, as a no-charge line item with pregnancy related diagnosis code.
  • When submitting claim for the first office post-partum visit, always include CPT-CAT-II 0503F, as a no-charge line item with an appropriate Z-code diagnosis.
  • When submitting claim for a subsequent post-partum visit, include CPT-CAT-II 0502F, as a no-charge line item with appropriate Z-code diagnosis.
• JHHP Priority Partners (PPMCO) Obstetric Services Policy RPC.008, in alignment with the authoritative outlined in the MDH provider manual and MDH transmittals, prohibits providers from submitting OB global (maternity care) procedure codes for PPMCO members. 
  • Providers are not to report global procedure codes 59400, 59425, 59426, 59510, 59610 and 59618.
  • Providers are to use the appropriate E/M code in conjunction with the appropriate ICD-10 pregnancy code for each prenatal visit and, bill delivers separately from prenatal care. 
  • Although the code listed above appears in the value set directory, State regulations prohibit these codes from being billed to Medicaid health plans. All related services must instead be submitted on a fee for service basis.
  • Use code 59430 for postpartum care services only. Postpartum care includes all visits in the hospital and office after the delivery. Postpartum care is not payable as a separate procedure unless it is provided by a physician or group other than the one providing the delivery service.
    • Use the appropriate CPT Category II codes to ensure accurate capture of postpartum visits when submitting claims for bundled delivery and postpartum services.

Prenatal Care with visit date and one of the following:

• A diagnosis of pregnancy (this must be included for PCP visits). Such as: visit to confirm pregnancy or pregnancy was diagnosed.
• Documentation indicating the member is pregnant or references to the pregnancy, for example: 
  • Standardized prenatal flow sheet, LMP, EDD, gestational age, gravidity and parity, notation of positive pregnancy test result, complete OB history, of prenatal risk assessment and counseling
  • A basic physical obstetrical examination with auscultation for fetal heart tone, pelvic exam, obstetric observations, or measurement of fundus height.
• Evidence that a prenatal care procedure was performed, such as: 
  • Screening test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing), OR
  • TORCH antibody panel, OR
  • Rubella antibody test/titer with RH incompatibility (ABO/Rh) blood typing, OR
  • Ultrasound of a pregnant uterus.

Prenatal Care Acceptable:

• May utilize ACOG sheet or a standardized prenatal flow sheet.
• Services provided during a telephone visit, e-visit or virtual check-in.

Prenatal Care Not acceptable:

• Ultrasound and lab results not combined with an office visit.
• A visit or documentation with a RN alone. It must be associated with appropriate provider's note.
• A Pap test does not count as a prenatal care visit.

Postpartum Care with visit date and one of the following:

• Notation of PP care, including, but not limited to: "postpartum care," "PP care, "PP check," 6-week check." (This alone will make member compliant)
• Assessment of breasts or breast feeding, weight, BP check and abdomen (breast feeding is acceptable for evaluation of breasts)
• Perineal or cesarean incision/wound check
• Screening for depression, anxiety, tobacco use, substance use disorder, or preexisting mental health disorders
• Pelvic exam-A pap test will count toward PP care as a pelvic exam.
• Glucose screening for member with gestational diabetes.
• Documentation of discussion any of the following topics:
  • Infant care / breastfeeding. 
  • Resumption of intercourse, birth spacing or family planning. 
  • Sleep or fatigue.
  • Resumption of physical activity.
  • Attainment of healthy weight.

Postpartum Care Not Acceptable:

• Colposcopy alone.
• Care in an acute inpatient setting.

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died any time during the measurement period.
• Pregnancy did not result in a live birth.
• Member not pregnant.
• Delivery outside of measure date parameters.

Measure Codes

Timeliness of Prenatal Care

Prenatal Bundled Services

• EHP/USFHP CPT: 59400, 59425, 59426, 59510, 59618, 59610
• PPMCO: Prenatal Bundle are not reimbursable.
• HCPCS: H1005

Stand Alone Prenatal Visits

• CPT/CPT-CAT-II: 99500, 0500F, 0501F, 05002F
• HCPCS: H1000, H1001, H1002, H1003, H1004
• SNOMED CT US Edition: 17629007, 18114009, 58932009, 66961001, 134435003, 135892000, 169600002, 169602005, 169603000, 169712008, 169713003, 169714009, 169715005, 169716006, 169717002, 169718007, 169719004, 169720005, 169721009, 169722002, 169723007, 169724001, 169725000, 169726004, 169727008, 171054004, 171055003, 171056002, 171057006, 171058001, 171059009, 171060004, 171061000, 171062007, 171063002, 171064008, 386235000, 386322007, 397931005, 406145006, 409010002, 422808006, 424441002, 424525001, 424619006, 439165004, 439733009, 439816006, 439908001, 440047008, 440227005, 440309009, 440536005, 440638004, 440669000, 440670004, 440671000, 441839001, 700256000, 702396006, 702736005, 702737001, 702738006, 702739003, 702740001, 702741002, 702742009, 702743004, 702744005, 710970004, 713076009, 713233004, 713234005, 713235006, 713237003, 713238008, 713239000, 713240003, 713241004, 713242006, 713386003, 713387007, 717794008, 717795009

A prenatal visit with a pregnancy-related diagnosis code

• CPT: 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98966, 98967, 98968, 98970, 98971, 98972, 98980, 98981, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99421, 99422, 99423, 99441, 99442, 99443, 99457, 99458, 99483
• HCPCS: G0071, G0463, G2010, G2012, G2250, G2251, G2252, T1015**
  
  • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC).
• SNOMED CT US Edition: 77406008. 185317003. 281036007. 314849005. 386472008. 386473003. 401267002

Pregnancy Diagnosis 

• ICD-10-CM Maternal conditions: O09.00-O9A.519*
• ICD-10-CM Encounter: Z03.71, Z03.72, Z03.73, Z03.74, Z03.75, Z03.79, Z32.01, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z36.0, Z36.1, Z36.2, Z36.3, Z36.4, Z36.5, Z36.81, Z36.82, Z36.83, Z36.84, Z36.85, Z36.86, Z36.87, Z36.88, Z36.89, Z36.8A, Z36.9 
• SNOMED CT US Edition: 9279009, 9899009, 14418008, 16356006, 29399001, 31601007, 34801009, 38720006, 41587001, 41991004, 43990006, 45307008, 47200007, 57630001, 58532003, 59466002, 60000008, 60810003, 64254006, 65147003, 65727000, 72892002, 77386006, 79290002, 79586000, 80997009, 82661006, 83074005, 87605005, 90968009, 102872000, 102875003, 169560008, 169561007, 169562000, 169563005, 169564004, 169565003, 169566002, 169567006, 169568001, 198624007, 198626009, 198627000, 199715003, 237233002, 237238006, 237239003, 237240001, 237241002, 237242009, 237244005, 239101008, 248985009, 281307002, 314204000, 442478007

*Please note that not all ICD-10-CM codes are listed here. For access to the complete set of codes related to Pregnancy Diagnosis Value Set, contact your Provider Engagement Liaison or email [email protected].

Postpartum Bundles Services

• CPT: 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622

Postpartum Visit

• CPT/CPT-CAT-II: 57170, 58300, 59430, 99501, 0503F
• HCPCS: G0101
• ICD-10-CM: Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2
• SNOMED CT US Edition: 133906008, 133907004, 169762003, 169770008, 169771007, 169772000, 384634009, 384635005, 384636006, 408883002, 408884008, 408886005, 409018009, 409019001, 431868002, 440085006, 717810008

Cervical Cytology

• CPT: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175 
• HCPCS: G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001
• LOINC: 104866-9, 10524-7, 18500-9, 19762-4, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

Cervical Cytology Result or Finding

• SNOMED CT US Edition168406009, 168407000, 168408005, 168410007, 168414003, 168415002, 168416001, 168424006, 250538001, 269957009, 269958004, 269959007, 269960002, 269961003, 269963000, 275805003, 281101005, 309081009, 310841002, 310842009, 416030007, 416032004, 416033009, 439074000, 439776006, 439888000, 441087007, 441088002, 441094005, 441219009, 441667007, 700399008, 700400001, 1155766001, 62051000119105, 62061000119107, 98791000119102