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Prenatal and Postpartum Care

EHP, Priority Partners/VBP, and USFHP. Women who had a live birth(s) on or between 10/8 year prior to the measurement year and 10/7 of the measurement year.

The percentage of live birth deliveries on or between October 8 of the year prior to the measurement year and October 7 of the measurement year. For these women, the measure assesses the following:

  • Timeliness of Prenatal Care: A prenatal care visit in the first trimester or within 42 days of enrollment in the health plan.
  • Postpartum Care: A postpartum visit on or between 7 and 84 days after delivery.

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

  • 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.
  • Can appear twice in the measure if two separate pregnancies during time frame.

Best Practice and Measure Tips

Prenatal Care with visit date and one of the following:

  • A diagnosis of pregnancy (this must be included for PCP visits).
  • Documentation indicating the woman 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, OB history,of prenatal risk assessment and counseling
    • PE with auscultation for fetal heart tone, obstetric observations, or measurement of fundus height.
  • Evidence that a prenatal care procedure was performed, such as:
    • Obstetric panel or TORCH antibody panel alone or rubella antibody test/titer with RH incompatibility (ABO/Rh) blood typing
    • Ultrasound of a pregnant uterus.

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.

Postpartum 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."(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 women with gestational diabetes.
  • Documentation of discussion any of the following topics:
    • Infant care / breastfeeding. Resumption of physical activity, intercourse, birth spacing or family planning. Sleep or fatigue.
    • Attainment of healthy weight.

Not Acceptable:

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

Measure Exclusions

Required Exclusions:

  • Hospice
  • Pregnancy did not result in a live birth
  • Member not pregnant
  • Delivery outside of measure date parameters

Measure Codes

  • Bundled service - codes may be used only if the claim indicates when prenatal care was initiated.
  • Visit for prenatal care
    • CPT/CPT II: 99500, 0500F-05002F
    • HCPCS: H1000-04
  • Prenatal visit
    • CPT/CPT II: 99201-05, 99211-15, 99241-45, 99483
    • HCPCS: G0463, T1015
    • Bundled service - codes may be used only if the claim indicates when PP care was rendered
      • CPT/CPT II: 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622
  • Postpartum Visits
    • CPT/CPT II: 57170, 58300, 59430, 99501, 0503F
    • HCPCS: G0101
    • ICD-10 Diagnosis: Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2
  • Cervical Cytology
    • CPT/CPT II: 88141-43, 88147-48, 88150, 88152-54, 88164-67, 88174-75
    • HCPCS: G0123-24, G0141, G0143-45, G0147-48, P3000, P3001, Q0091