Current through Vol. 42, No. 1, September 16, 2024
(a) Obstetrical
(OB) care is billed using the appropriate CPT codes for maternity care and
delivery. The date of delivery is used as the date of service for charges for
total OB care. Inclusive dates of care should be indicated on the claim form as
part of the description. Payment for total OB care includes all routine care,
and any ultrasounds performed by the attending physician provided during the
maternity cycle unless otherwise specified in this Section. For payment of
total OB care, a physician must have provided care for more than one (1)
trimester. To bill for prenatal care only, the claim is filed after the member
leaves the provider's care. Payment for routine or minor medical problems will
not be made separately to the OB physician outside of the antepartum visits.
The antepartum care during the prenatal care period includes all care by the OB
attending physician except major illness distinctly unrelated to the
pregnancy.
(b) Procedures paid
separately from total OB care are listed in (1) - (8) of this subsection.
(1) The completion of an American College of
Obstetricians and Gynecologist (ACOG) assessment form or form covering same
elements as ACOG, and the most recent version of the Oklahoma Health Care
Authority's (OHCA) Prenatal Psychosocial Assessment are reimbursable when both
documents are included in the prenatal record. SoonerCare allows one (1)
assessment per provider and no more than two (2) per pregnancy.
(2) Medically necessary real time antepartum
diagnostic ultrasounds will be paid in addition to antepartum care, delivery,
and postpartum OB care under defined circumstances. To be eligible for payment,
all ultrasound reports must meet the guideline standards published by the
American Institute of Ultrasound Medicine (AIUM).
(A) One (1) ultrasound will be covered in the
first trimester of an uncomplicated pregnancy. Both an abdominal and vaginal
ultrasound may be allowed when clinically appropriate and medically necessary.
The ultrasound must be performed by a board eligible/board certified
obstetrician-gynecologist (OB-GYN), radiologist, or a board eligible/board
certified maternal-fetal medicine specialist. In addition, this ultrasound may
be performed by a certified nurse midwife (CNM), family practice physician or
advanced practice nurse practitioner (APRN) in obstetrics with a certification
in OB ultrasonography.
(B) One (1)
ultrasound after the first trimester will be covered. This ultrasound must be
performed by a board eligible/board certified OB-GYN, radiologist, or a board
eligible/board certified maternal-fetal medicine specialist. In addition, this
ultrasound may be performed by a CNM, family practice physician, or APRN with
certification in OB ultrasonography.
(C) One (1) additional detailed ultrasound is
allowed by a board eligible/board certified maternal fetal specialist or
general obstetrician with documented specialty training in performing detailed
ultrasounds. This additional ultrasound is allowed to identify or confirm a
suspected fetal/maternal anomaly. This additional ultrasound does not require
prior authorization. Any subsequent ultrasounds will require prior
authorization.
(3)
Standby attendance at cesarean section (C-section), for the purpose of
attending the baby, is compensable when billed by a physician or qualified
health care provider not participating in the delivery.
(4) Anesthesia administered by the attending
physician is a compensable service and may be billed separately from the
delivery.
(5) Amniocentesis is not
included in routine OB care and is billed separately. Payment may be made for
an evaluation and management service and a medically indicated amniocentesis on
the same date of service. This is an exception to general information regarding
surgery found at Oklahoma Administrative Code (OAC)
317:30-5-8.
(6) Additional payment is not made for the
delivery of multiple gestations. If one (1) fetus is delivered vaginally and
additional fetus(es) are delivered by C-section by the same physician, the
higher-level procedure is paid. If one (1) fetus is delivered vaginally and
additional fetus(es) are delivered by C-section, by different physicians, each
should bill the appropriate procedure codes without a modifier. Payment is not
made to the same physician for both standby and assistant at
C-section.
(7) Reimbursement is
allowed for nutritional counseling in a group setting for members with
gestational diabetes. Refer to OAC
317:30-5-1076(5).
(8) Limited OB ultrasounds are covered in an
emergency room (ER) setting when medically necessary.
(c) Assistant surgeons are paid for
C-sections which include only in-hospital post-operative care. Family
practitioners who provide prenatal care and assist at C-section bill separately
for the prenatal and the six (6) weeks postpartum office visit.
(d) Procedures listed in (1) - (5) of this
subsection are not paid or not covered separately from total OB care.
(1) Non stress test unless the pregnancy is
determined medically high risk. See OAC
317:30-5-22.1.
(2) Standby at C-section is not compensable
when billed by a physician participating in delivery.
(3) Payment is not made for an assistant
surgeon for OB procedures that include prenatal or postpartum care.
(4) An additional allowance is not made for
induction of labor, double set-up examinations, fetal stress tests, or pudendal
anesthetic. Providers must not bill separately for these procedures.
(5) Fetal scalp blood sampling is considered
part of the total OB care.
(e) OB coverage for children is the same as
for adults. Additional procedures may be covered under Early and Periodic
Screening, Diagnostic and Treatment (EPSDT) provisions if determined to be
medically necessary.
(1) Services deemed
medically necessary and allowable under federal Medicaid regulations are
covered by the EPSDT/OHCA Child Health Program even though those services may
not be part of the OHCA SoonerCare program. Such services must be prior
authorized.
(2) Federal Medicaid
regulations also require the State to make the determination as to whether the
service is medically necessary and do not require the provision of any items or
services that the State determines are not safe and effective or which are
considered experimental. For more information regarding experimental or
investigational and clinical trials see OAC 317:30-3-57.1.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 14 Ok Reg 2394, eff 5-28-97 (emergency); Amended at 15 Ok
Reg 1528, eff 5-11-98; Amended at 16 Ok Reg 3413, eff 7-1-99 (emergency);
Amended at 17 Ok Reg 708, eff 1-10-00 (emergency); Amended at 17 Ok Reg 1204,
eff 5-11-00; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 21 Ok Reg 2176,
eff 6-25-04; Amended at 24 Ok Reg 207, eff 11-1-06 (emergency); Amended at 24
Ok Reg 895, eff 5-11-07; Amended at 25 Ok Reg 426, eff 11-1-07 (emergency);
Amended at 25 Ok Reg 658, eff 1-1-08 (emergency); Amended at 25 Ok Reg 1161,
eff 5-25-08; Amended at 26 Ok Reg 100, eff 8-1-08 (emergency); Amended at 26 Ok
Reg 254, eff 12-1-08 (emergency); Amended at 26 Ok Reg 1059, eff 5-11-09;
Amended at 26 Ok Reg 1766, eff 7-1-09 (emergency); Amended at 27 Ok Reg 108,
eff 10-2-09 (emergency); Amended at 27 Ok Reg 946, eff
5-13-10
