Maternity/Obstetrical Care Benefits - CAM 366

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 noncomplicated 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 (e.g., 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.

Standby 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:

It is 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.

Related Policy: CAM 358 genetic prenatal screening

**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 CONTRACTION STRESS TEST
	59025	FETAL NON-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 Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

History From 2014 Forward

02/05/2024	Annual review, no change to policy intent. Also corrected the verbiage for CPT 59020 and 59025, they were inverted.
02/08/2023	Annual review, no change to policy intent.
02/01/2022	Annual review, no change to policy intent.
02/08/2021	Annual review, no change to policy intent.
02/03/2020	Annual review, no change to policy intent.
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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Maternity/Obstetrical Care Benefits - CAM 366