CAM 366

Maternity/Obstetrical Care Benefits

Category:Other   Last Reviewed:February 2019
Department(s):Medical Affairs   Next Review:February 2020
Original Date:July 1998    

Description:
Maternity/obstetrical care is the care of a pregnant female before, during and after the delivery of a child.

Policy Statement:
Most contracts of this health plan provide benefits for maternity/obstetrical care. The purpose of this policy is to outline and describe payment benefits of service(s) for those conditions that represent non-complicated and complicated conditions related to pregnancy.

Maternity Benefits:
Maternity care benefits are reimbursable under the following conditions for covered members:

Global care, which includes:

  • Antepartum Care: Initial and subsequent history, physical examination, recording of weight, blood pressures, fetal heart tones, routine chemical analysis (U/A), finger stick tests during each visit. Typically, there are monthly visits up to 28 weeks gestation, bi-weekly visits up to 36 weeks gestation and then weekly visits until delivery. There are times, however, that additional visits may be needed. Additional visits directly related to the pregnancy (e.g., cramping, abdominal pain, urinary tract infection, breast tenderness, etc.) are considered to be part of the global care and, as such, are not reimbursed separately. If the patient is seen for a condition that is NOT related to her pregnancy (ex., sinusitis, broken bones, etc.) the office visit may be reimbursed separately.
  • Delivery: This includes admission to the hospital, including history and physical examination, management of an uncomplicated labor, vaginal (with or without episiotomy, with or without forceps) or cesarean section.  Multiple births are not considered a complication in the absence of other extenuating circumstances (an example of a complication would be abrupto placenta, uterine rupture, failure to progress in labor with maternal or fetal distress).
  • Postpartum Care: Includes hospital and office visits following vaginal or cesarean section delivery.

Lab Work:  An obstetrical lab panel is reimbursable outside of the global care benefits.  This panel must include the following:

  • Hemogram, automated and manual differential WBC count OR hemogram and platelet count, automated and automated differential WBC count
  • Hepatitis B surface antigen (HbsAg)
  • Antibody, rubella
  • Syphilis test, qualitative (e.g., VDRL, RPR, ART)
  • Blood typing, ABO and blood typing Rh (D)
  • Multiple serum marker testing (human chorionic gonadotropin [hCG] with maternal serum alpha-fetoprotein [MSAFP], unconjugated estriol and dimeric inhibin A) is considered MEDICALLY NECESSARY for pregnant women who have been adequately counseled and who desire information on their risk of having a Down syndrome fetus.
  • Screening culture, presumptive, pathogenic organisms for Beta Strep
  • An initial presumptive urine drug screening

Fetal Non-Stress Testing: This test is a diagnostic procedure that gives an indirect assessment of the status of the pregnancy by assessing the fetal heart rate, fetal movement and uterine contractibility. It is appropriate for use for any condition that may affect the fetal outcome, such as hypertension, history of premature labor, intrauterine growth retardation, pre-eclampsia, etc.

Ultrasounds: An obstetrical ultrasound is the visualization of the inner structures by recording the reflections of pulses of ultrasonic waves directed into the tissues. The use of an ultrasound is considered to be a medically necessary tool in pregnancies from 10-18 weeks gestation. More than two or repeat ultrasounds during the course of a pregnancy require medical justification. Such justifications would include, but are not limited to, the following:

  • Increased risk factors (e.g., personal or family history of congenital anomalies)
  • High-risk factors (e.g., maternal diabetes, alcohol/drug addition, malnutrition)
  • Elderly primigravida
  • Suspected abnormalities of pregnancy (e.g., hydatidiform mole, ectopic pregnancy, threatened/missed abortion, congenital malformation, placenta previa, abrupto placenta, vaginal bleeding)
  • Pre-/post-amniocentesis studies
  • Suspected abnormal presentation of fetus
  • Suspected multiple fetuses
  • Suspected fetal demise
  • Gynecologic or other pelvic masses
  • Significant fetal growth abnormality as indicated by a discrepancy of fetal size and estimated age

Amniocentesis: An obstetrical procedure in which a small amount of amniotic fluid is removed for laboratory analysis.  It is usually performed between 16 and 20 weeks of gestation to aid in the diagnosis of fetal abnormalities.  An amniocentesis is typically performed for conditions, such as:

  • The patient is of an advanced age at time of conception (35 years or older)
  • Has a child or an immediate family history of a child with a neural tube defect
  • Has a child with or has an immediate family history of multiple abnormalities
  • Has a child with RH sensitization or a current fetus with indication of RH sensitization
  • The patient has medical problems that complicate pregnancy and require induction to determine fetal maturity
  • The patient has a child with or an immediate family history of chromosomal abnormalities, sex linked abnormalities or autosomal recessive abnormalities that can be diagnosed prenatally
  • History of multiple spontaneous abortions (in this current marriage or in a previous mating of either spouse)

An infrequent indication for an amniocentesis is for fetal sex determination for pregnancies, which are at risk for X-linked heredity disorders. This would include such conditions as:

  • Severe hemophilia
  • X-linked mental retardation
  • X-linked hydrocephalus
  • Duchenne muscular dystrophy

Benefits are NOT provided for an amniocentesis performed purely for sex determination in the absence of documented risk factors.

Multiple Births:
The delivery of multiple births is NOT considered a complication of pregnancy in the absence of other complications or risk factors. In the event that there is a complication of pregnancy or delivery, the provider should file the appropriate modifier to indicate such complications for consideration of additional reimbursement.

Stand By Physicians:  A physician who is asked to "stand by" during certain medical/surgical procedures or situations where the physician is needed to examine, diagnose or treat a patient should a complication arise. Attendance at high-risk delivery is a covered service when the delivery results in a healthy infant and the following are met:

  • Requested by the attending physician
  • There is documentation of fetal distress or reasonable anticipation of newborn distress as in the situation stated above
  • The pediatrician is directly involved in providing services to the infant

Tubal Ligation During or After Delivery:  If a tubal ligation is performed after a vaginal delivery, the procedure will be reimbursed at 100 percent of the allowable amount for the procedure. If the tubal ligation is performed during a cesearean section birth, the procedure will be reimbursed at 50 percent of the allowable amount for the procedure.

Anesthesia By The Attending Obstetrician or Delivering Physician:
If the attending delivering obstetrician/physician performs the insertion of the epidural anesthesia and maintains that anesthesia, he/she may be reimbursed 50 percent of the allowable amount for that procedure.

**PLEASE SEE SPECIFIC CONTRACTS FOR LIMITATIONS AND EXCLUSIONS RELATED TO MATERNITY/OBSTETRICAL BENEFITS**

Coding Section

Codes Number Description
CPT 0502F

SUBSEQUENT PRENATAL CARE VISIT (PRENATAL) (EXCLUDES: PATIENTS WHO ARE SEEN FOR A CONDITION UNRELATED TO PREGNANCY OR PRENATAL CARE (E.G., AN UPPER RESPIRATORY INFECTION; PATIENTS SEEN FOR CONSULTATION ONLY, NOT FOR CONTINUING CARE)) 

  0503F

POSTPARTUM CARE VISIT (PRENATAL)

  00842

ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN LOWER ABDOMEN INCLUDING LAPAROSCOPY; AMNIOCENTESIS

  01958

ANESTHESIA FOR EXTERNAL CEPHALIC VERSION PROCEDURE

  01960

ANESTHESIA FOR VAGINAL DELIVERY ONLY

  01961

ANESTHESIA FOR CESAREAN DELIVERY ONLY

  01962

ANESTHESIA FOR URGENT HYSTERECTOMY FOLLOWING DELIVERY

  01963

ANESTHESIA FOR CESAREAN HYSTERECTOMY WITHOUT ANY LABOR ANALGESIA/ANESTHESIA CARE

  01967

NEURAXIAL LABOR ANALGESIA/ANESTHESIA FOR PLANNED VAGINAL DELIVERY (THIS INCLUDES ANY REPEAT SUBARACHNOID NEEDLE PLACEMENT AND DRUG INJECTION AND/OR ANY NECESSARY REPLACEMENT OF AN EPIDURAL CATHETER DURING LABOR)

  01968

ANESTHESIA FOR CESAREAN DELIVERY FOLLOWING NEURAXIAL LABOR ANALGESIA/ANESTHESIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE PERFORMED)

  01969

ANESTHESIA FOR CESAREAN HYSTERECTOMY FOLLOWING NEURAXIAL LABOR ANALGESIA/ANESTHESIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE PERFORMED)

  57022

INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM 

  58605

LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, POSTPARTUM, UNILATERAL OR BILATERAL, DURING SAME HOSPITALIZATION (SEPARATE PROCEDURE)

  58611

LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT THE TIME OF CESAREAN DELIVERY OR INTRA-ABDOMINAL SURGERY (NOT A SEPARATE PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

  59000

AMNIOCENTESIS; DIAGNOSTIC

  59001

AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUID REDUCTION (INCLUDES ULTRASOUND GUIDANCE)

  59020 FETAL NON-STRESS TEST
 

59025

FETAL CONTRACTION STRESS TEST

  59160

CURETTAGE, POSTPARTUM

  59200

INSERTION OF CERVICAL DILATOR (E.G., LAMINARIA, PROSTAGLANDIN) (SEPARATE PROCEDURE) 

  59300

EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING

  59320

CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL 

  59325

CERCLAGE OF CERVIX, DURING PREGNANCY; ABDOMINAL 

  59350

HYSTERORRHAPHY OF RUPTURED UTERUS 

  59400

ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) AND POSTPARTUM CARE 

  59409

VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); 

  59410

VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); INCLUDING POSTPARTUM CARE 

  59414

DELIVERY OF PLACENTA (SEPARATE PROCEDURE) 

  59425

ANTEPARTUM CARE ONLY; 4-6 VISITS 

  59426

ANTEPARTUM CARE ONLY; 7 OR MORE VISITS 

  59430

POSTPARTUM CARE ONLY (SEPARATE PROCEDURE) 

  59510

ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN DELIVERY AND POSTPARTUM CARE 

  59514

CESAREAN DELIVERY ONLY; 

  59515

CESAREAN DELIVERY ONLY; INCLUDING POSTPARTUM CARE 

  59525

SUBTOTAL OR TOTAL HYSTERECTOMY AFTER CESAREAN DELIVERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 

  59610 

ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) AND POSTPARTUM CARE, AFTER PREVIOUS CESAREAN DELIVERY 

  59612

VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); 

  59614 

VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); INCLUDING POSTPARTUM CARE 

  59618

ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN DELIVERY AND POSTPARTUM CARE, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN DELIVERY 

  59620

CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN DELIVERY; 

  59622

CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN DELIVERY; INCLUDING POSTPARTUM CARE 

  59871

REMOVAL OF CERCLAGE SUTURE UNDER ANESTHESIA (OTHER THAN LOCAL) 

  76801

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION,

  76802

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

  76805

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION 

  76810

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

  76811

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION PLUS DETAILED FETAL ANATOMIC EXAMINATION, TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION

  76812

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION PLUS DETAILED FETAL ANATOMIC EXAMINATION, TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

  76813

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION

  76814

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

  76815

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (E.G., FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES

  76816

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (E.G., RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS

  76817

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL

  76818

FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING

  76819

FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING

  76820

DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY

  76821

DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY

  76825

ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING;

  76826

ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR REPEAT STUDY

  76827

DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY; COMPLETE

  76828

DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY; FOLLOW-UP OR REPEAT STUDY

  76946

ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, IMAGING SUPERVISION AND INTERPRETATION

  80055

OBSTETRIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: BLOOD COUNT, COMPLETE (CBC), AUTOMATED AND AUTOMATED DIFFERENTIAL WBC COUNT (85025 OR 85027 AND 85004) OR BLOOD COUNT, COMPLETE (CBC), AUTOMATED (85027) AND APPROPRIATE MANUAL DIFFERENTIAL WBC COUNT (85007 OR 85009) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) ANTIBODY, RUBELLA (86762) SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (E.G., VDRL, RPR, ART) (86592) ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE (86850) BLOOD TYPING, ABO (86900) AND BLOOD TYPING, RH (D) (86901)

  82105  ALPHA-FETOPROTEIN (AFP); SERUM
  82106

ALPHA-FETOPROTEIN (AFP); AMNIOTIC FLUID 

  83662

FETAL LUNG MATURITY ASSESSMENT; FOAM STABILITY TEST 

  85004

BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT 

  85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBCCOUNT
  85009

BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT 

  85014

BLOOD COUNT; HEMATOCRIT (HCT) 

    85018

BLOOD COUNT; HEMOGLOBIN (HGB)

  85025

BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT 

  85027

BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) 

  85032 BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE OR PLATELET) EACH
  85048

BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 

  85049 BLOOD COUNT; PLATELET, AUTOMATED
  86592

SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (E.G., VDRL, RPR, ART)

  86762

ANTIBODY; RUBELLA

  86900

BLOOD TYPING; ABO

  86901

BLOOD TYPING; RH (D)

  87077

CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE 

  87081

CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; 

  87340

INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS B SURFACE ANTIGEN (HBSAG)

  87653

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP B, AMPLIFIED PROBE TECHNIQUE

  87802

INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; STREPTOCOCCUS, GROUP B 

  99360

STANDBY SERVICE, REQUIRING PROLONGED ATTENDANCE, EACH 30 MINUTES (E.G., OPERATIVE STANDBY, STANDBY FOR FROZEN SECTION, FOR CESAREAN/HIGH-RISK DELIVERY, FOR MONITORING EEG) 

  99500 

HOME VISIT FOR PRENATAL MONITORING AND ASSESSMENT TO INCLUDE FETAL HEART RATE, NON-STRESS TEST, UTERINE MONITORING AND GESTATIONAL DIABETES MONITORING 

HCPC  G0431

DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES BY HIGH COMPLEXITY TEST METHOD (E.G., IMMUNOASSAY, ENZYME ASSAY), PER PATIENT ENCOUNTER

  G0434 

DRUG SCREEN, OTHER THAN CHROMATOGRAPHIC; ANY NUMBER OF DRUG CLASSES, BY CLIA WAIVED TEST OR MODERATE COMPLEXITY TEST, PER PATIENT ENCOUNTER

  G0477 

Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service. 

  G0478 

Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service. 

  G0479 

Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service. 

  H1001 

PRENATAL CARE, AT-RISK ENHANCED SERVICE; ANTEPARTUM MANAGEMENT 

  S3625

MATERNAL SERUM TRIPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN (AFP), ESTRIOL AND HUMAN CHORIONIC GONADOTROPIN (HCG) 

  S3626

MATERNAL SERUM QUADRUPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN (AFP), ESTRIOL, HUMAN CHORIONIC GONADOTROPIN (HCG) AND INHIBIN A 

  S9212 

HOME MANAGEMENT OF POSTPARTUM HYPERTENSION, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE) 

  S9438 

CESAREAN BIRTH CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION 

  S9439  VBAC (VAGINAL BIRTH AFTER CESAREAN) CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
  S9442 

BIRTHING CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION 

ICD-9 Diagnosis 181 MALIGNANT NEOPLASM OF PLACENTA
  2361

NEOPLASM OF UNCERTAIN BEHAVIOR OF PLACENTA

  62981

RECURRENT PREGNANCY LOSS WITHOUT CURRENT PREGNANCY 

  630-67914

COMPLICATION OF PREGNANCY CHILDBIRTH AND PUERPERIUM 

  7600-7639

MATERNAL CAUSES OF PERINATAL MORBIDITY AND MORTALITY 

  7640-7799

OTHER CONDITIONS ORIGINATION IN THE PERINATAL PERIOD.  ***Please note that some of these diagnoses, although associated with the perinatal period, are generally used for the newborn and not the mother.  

  7923

NONSPECIFIC ABNORMAL FINDINGS IN AMNIOTIC FLUID

  7965

ABNORMAL FINDING ON ANTENATAL SCREENING

  V220 - V242

PREGNANCY, HIGH-RISK PREGNANCY, POSTPARTUM CARE AND EXAM 

  V270-V279

OUTCOME OF DELIVERY

  V280-V289

ENCOUNTER FOR ANTENATAL SCREENING OF MOTHER

  V3000-V3921

LIVEBORN INFANTS ACCORDING TO TYPE OF BIRTH

  V616

ILLEGITIMACY OR ILLEGITIMATE PREGNANCY 

  V617

OTHER UNWANTED PREGNANCY 

  V7240-V7242

PREGNANCY EXAMINATION OR TEST 

  V890-V8909

OTHER SUSPECTED CONDITIONS NOT FOUND

  V9100-V9199

MULTIPLE GESTATION PLACENTA STATUS 

 ICD-10-CM (effective 10/01/15)  C58

Malignant neoplasm of placenta 

   D392

Neoplasm of uncertain behavior of placenta 

   N96

Recurrent pregnancy loss 

  O00-O9A

Pregnancy, childbirth and the Puerperium

  P00-P96 Certain Conditions Originating in the Perinatal Period
  Z3400

Encounter for supervision of normal first pregnancy, unspecified trimester

  Z3480

Encounter for supervision of normal first pregnancy, unspecified trimester

  Z3490

Encounter for supervision of normal pregnancy, unspecified, unspecified trimester

  Z331 

Pregnant state, incidental

  Z390

Encounter for care and examination of mother immediately after delivery

  Z391

Encounter for care and examination of lactating mother

  Z392

Encounter for routine postpartum follow-up 

  Z37-Z379

Outcome of Delivery

  Z36 

Encounter for antenatal screening of mother 

  Z38-Z388 

Liveborn infants according to place of birth and type of birth

  Z640 

Problems related to unwanted pregnancy 

  Z3200

Encounter for pregnancy test, result unknown 

  Z3202 

Encounter for pregnancy test, result negative 

  Z3201 

Encounter for pregnancy test, result positive 

  Z0371 

Encounter for suspected problem with amniotic cavity and membrane ruled out 

  Z0372 

Encounter for suspected placental problem ruled out 

  Z0373  Encounter for suspected fetal anomaly ruled out 
  Z0374  Encounter for suspected problem with fetal growth ruled out 
  Z0375 

Encounter for suspected cervical shortening ruled out 

  Z0379 

Encounter for other suspected maternal and fetal conditions ruled out 

  O30009-O030099 

Twin Gestation

 
O030109-O030199 

Triplet Gestation 

  O30209-O03299 

Quadruplet Gestation 

  O30809-O30899 

Other specified multiple Gestation 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

02/01/2019 

Annual review, no change to policy intent. 

01/31/2018 

Annual review, no change to policy intent. 

02/08/2017 

Annual review, no change to policy intent. Updating coding to include G0477-G0479. 

03/01/2016 

Annual review, no change to policy intent. 

09/24/2015

Added ICD-10 coding to policy. 

03/25/2015

Annual review, no change to policy intent. Added coding. Adding an initial presumptive drug screening to the lab section

03/4/2014

Annual review. No changes made.


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