Product Lines:
EHP, Priority Partners, and USFHP.

Eligible Population:
Women who had a live birth(s) on or between 10/8 year prior to the MY and 10/7 of the MY (10/8/2023 -10/7/2024). This includes Value Based Purchasing (VBP) for Priority Partners.

Definition:
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.

Report stratification by race and ethnicity.

Continuous Enrollment:

• 43 days prior to delivery through 60 days after delivery.

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.  
• Follow members closely who have or had a substance abuse or mental health diagnosis. Initiate appropriate 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.
• 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).
• Use appropriate and accurate codes on claims.
• Use appropriate CPT Category II codes for pregnancy diagnosis office visits and postpartum visits when submitting claims for bundle maternity services. 
  • CPT Category II helps identify clinical outcomes
  • Reduce the need for some chart review

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.

Acceptable:

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

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 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 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.

Not Acceptable:

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

Measure Exclusions

Required Exclusions:

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

Measure Codes

•    Prenatal Visit 
  • Stand Alone Prenatal Visits 
    • CPT/CPT II: 99500, 0500F - 05002F
    • HCPCS: H1000 - H1004
  • Office Visit with a pregnancy related diagnosis code
    • CPT: 98966, 98967, 98968, 98970, 98971, 98972, 98980, 98981, 99202-99205, 99211-99215, 99241-99245, 99421-99423, 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).
  • Prenatal bundled service - codes may be used only if the claim indicates when prenatal care was initiated.
    • CPT: 59400, 59425, 59426, 59510, 59610, 59618, 
    • HCPCS: H1005
• Postpartum Visits 
  • CPT/CPT II: 57170, 58300, 59430, 99501, 0503F
  • HCPCS: G0101
  • ICD-10-CM: Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2
  • Postpartum bundled services - codes may be used only if the claim indicates when PP care was rendered.
    • CPT: 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622
• Cervical Cytology 
  • CPT: 88141-88143, 88147, 88148, 88150, 88152, 88153, 88164-88167, 88174-88175
  • HCPCS: G0123, G0124, G0141, G0143, G0145, G0147-48, P3000, P3001, Q0091