CPT CODE and Description
H1000 PRENATAL CARE, AT-RISK ASSESSMENT
H1001 Prenatal care, at-risk enhanced service; antepartum management
H1003 Prenatal care, at-risk enhanced service; education
HCPCS Code H1000 – Prenatal care atriskassessm
Risk Assessment
Risk assessment is the systematic review of relevant member data to identify potential problems and determine a plan for care. Early identification of high risk pregnancies with appropriate consultation and intervention contributes significantly to an improved perinatal outcome and lowering of maternal and infant morbidity and mortality. A care plan for high risk members, in addition to standard care, includes referral to or consultation with an appropriate specialist, individualized counseling and services designed to address the risk factor(s) involved. A care plan for low risk members includes primary care services and additional services specific to the needs of the individual.
Risk Assessments may be provided by one of the following licensed Medicaid providers:
** Physician
** Certified Nurse Practitioner
** Certified Nurse-Midwife
The service is reported using HCPCS H1000 Prenatal Care, At Risk Assessment for a low risk assessment or HCPCS H1001 Prenatal Care, At Risk Enhances Service; Antepartum Management for high risk assessment. Limited to two (2) assessments during any 10-month period.
Single Prenatal Visit(s) Other than Initial Visit
A single prenatal visit other than the initial visit is a single prenatal visit for an established member who does not return to complete care for unknown reasons. The initial assessment visit was completed, a plan of care established, one or two follow-up visits completed, without further care provided.
Single Prenatal Visit may be provided by one of the following licensed Medicaid providers:
** Physician
** Certified Nurse Practitioner
** Certified Nurse-Midwife
The service is reported using an appropriate CPT E/M code. Limited to three (3) visits in any 10-month period. The service may be billed only when the member is lost to follow up for any reason.
Prenatal Assessment Visit (Initial Visit Only)
The initial prenatal assessment visit is a single prenatal visit for a new patient with a confirmed pregnancy, providing an evaluation of the mental and physical status of the patient, an in depth family and medical history, physical examination, development of the medical data and initiation of a plan of care.
Prenatal Assessment Visit may be provided by one of the following licensed Medicaid providers:
** Physician
** Certified Nurse Practitioner
** Certified Nurse-Midwife
The service is reported using an appropriate CPT E/M code. Limited to one (1) visit in any 10-month period, to be used only when the patient is referred immediately to a community practitioner because of identified risks or otherwise lost to follow-up because the patient does not return.
Billing Guidelines from Uhc
Florida
** Prenatal care must be billed separately from the delivery and postpartum care.
** FL providers are to submit prenatal codes H1001 and/or H1000.
** Up to 10 visits are allowed for prenatal care.** Up to two postpartum visits are allowed within 90 days following delivery, per recipient.
** Delivery of two or more infants from a single pregnancy, by different delivery method, separately. Same delivery method is non-covered
BCBS insurance Guidelines
Pre-term Birth Prevention Services
Blue Cross will reimburse for certain pre-term birth prevention serviceswhen the patient’s contract covers these services.
CODE NARRATIVE BILLING
H1001 Prenatal care, at-risk enhancedservice; antepartum management If the patient isidentified via the assessment as high risk. This code may be billed once.
H1003 Prenatal care, at-risk enhanced If the patient isidentified via the assessment as high risk. This code may be billed once.
The services represented by the prenatal care at-risk codes H1002, H1004 and H1005 are already included in the provider’s normal prenatal care and not separately reimbursed.
All Prenatal visits must be billed using the appropriate E&M code for each prenatal visit. Specific CPT and HCPCS Codes are listed. MFC has included a list of CPT Codes provided by MDH. This list is subject to change at any time without notice when MDH updates their On-Line information.
** Delivery services can be billed 1 of 2 ways: o Delivery Service + Post Partum Care o Delivery Services Only
** Providers may bill: o H1000 (Risk Assessment) once per pregnancy o H1003 (Enhanced Services) once per visit for Maryland Medicaid members. Providers must document in the medical record that health education and counseling appropriate to the needs of the pregnant woman was provided.
** OBs must bill for circumcisions under the infant’s own name and Medicaid Number /MFC Number.** For procedure codes with a global value MMM, the global period equals 56 days.
** When a provider bills a delivery + post partum care at the time of delivery, the provider must rebill using the exact same codes when the post partum visit actually takes place and adding the modifier TH to the claim. Use of this modifier however will indicate he date that the postpartum visit actually occurred. The postpartum visit has to occur on or between 21 and 56 days after delivery. ** If the provider bills the delivery only code, and then later bills the delivery + postpartum code to indicate that the postpartum visit occurred, the original delivery only payment is retracted and the delivery + postpartum code billed is paid
Timeliness of Prenatal Care
Measurement: Deliveries that received prenatal care visit in the first trimester or within 42 days of enrollment in a health plan.
Required documentation in the medical record for PRENATAL care visit:
1)A basic physical obstetrical examination that includes
** Auscultation for fetal heart tone, or ** Pelvic exam with obstetric observations, or
** Measurement of fundus height (a standardized prenatal flow sheet may be used)
2)Prenatal Care Procedure: Could be:
** Screening test/obstetric panel or ** TORCH antibody panel alone, or
** A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, or
** Ultrasound/Echography of a pregnant uterus
3)Documentation of LMP or EDD with either prenatal risk assessment & counseling/education, or complete obstetrical history
Required coding for PRENATAL care visit:
Stand Alone Prenatal Visits
CPT: 59425, 59426,99201-99205, 99211-99215, 99241-99245, 99500
CPT II: 0500F, 0501F, 0502F
HCPCS: H1000, H1001, H1002, H1003, H1004
