Many obstetric services covered by MHCP are considered preventative health services. If the service is a preventative health service, the provider must have a written recommendation before providing services. The written recommendation must come from a physician, advanced practice nurse or physician assistant.

Prenatal Screening and Enhanced Services for High-risk Pregnancies

Providers should screen all pregnant MHCP members using a standardized prenatal risk assessment tool. This could include using the American College of Obstetricians and Gynecologists’ Obstetric Medical History, or an assessment tool developed or customized in the provider’s office and is equivalent to one of the standardized tools. Keep a copy of the prenatal risk assessment in the member’s record. The assessment tool, whether standardized or customized, must maintain the information in a single document that can be easily separated from the medical record for review.

Providers may determine that a member is at high-risk for an adverse birth outcome based on information from the prenatal assessment and screening process. Members determined to be high-risk are eligible for enhanced services. The primary care provider is responsible for ordering and referring a high-risk member to enhanced services. MHCP encourages providers to address these issues throughout the pregnancy.

Enhanced Services for High-risk Pregnancies
The following enhanced services are covered for high-risk pregnancies:

· High-risk antepartum management

· Care coordination

· Prenatal health education I

· Prenatal health education II: Lifestyle and parenting support

· Prenatal nutrition education

· Postpartum follow-up home visit

Refer to Billing Enhanced Services for limits and eligible providers.

High-risk Antepartum Management (H1001)
A primary care provider is eligible for MHCP payment for the additional time and expertise required to manage the member’s care beyond routine prenatal care when the member is identified as having a high-risk pregnancy. The primary care provider who is responsible for the member’s care during pregnancy determines what additional health services would benefit the member and provides medical care as determined by the member’s needs.

Care Coordination (H1002)
Care coordination is the development, implementation and ongoing evaluation of the plan of care for a high-risk pregnant person. The care coordinator provides continuity, makes referrals, monitors the member’s progress and advocates for the member to ensure access to services that support a healthy pregnancy and improve birth outcomes.

Care coordination services include the following:

· Documentation that the pregnant person is at high-risk for an adverse birth outcome

· Development of an individual plan of care that addresses the member’s specific needs and risks related to the pregnancy

· Ongoing evaluation and, when appropriate, revision of the plan of care

· Involvement of the pregnant person and their support network in the assessment and plan of care

· Coordination of services and referrals to appropriate community resources and health care providers

· Advocacy for the pregnant person in working with health care providers

· Monitoring, on an ongoing basis, to determine whether the member is receiving enhanced prenatal services in a timely and economical manner, and that each service is of expected and adequate quality

Documentation Requirements for Care Coordination
Documentation requirements include the following:

· A written, individualized plan of care that addresses the member’s specific needs related to the pregnancy, including any revisions of that plan

· Evidence of all referrals made, and follow-up on those referrals

· Evidence of the following activities: monitoring, coordinating and managing nutrition and prenatal education services to ensure that they are provided in the most economical and efficient manner

Prenatal Health Education
Health education for the high-risk pregnant person is a core intervention that is preventive, resource-efficient and consistent with the member’s individualized plan of care. Educational services are based on the pregnant person’s risks as identified on the prenatal screening tool, and their needs as determined by the primary care provider and care coordinator in consultation with the pregnant person.

These members require innovative and individualized approaches to prenatal care to effectively meet their educational needs. Educational interventions target risk factors, medical conditions and health behaviors that can be alleviated or improved through education. Educational services begin with the initial assessment visit and continue throughout the perinatal period. Services can be provided on a one-to-one basis, in small-group settings or in classes individualized to the person’s own needs and interests. Prenatal health education promotes a healthy lifestyle that will support a healthy pregnancy and result in an improved perinatal outcome.

Prenatal Health Education I (H1003) provides general information about pregnancy and prenatal care. It also covers high-risk medical conditions and lifestyle factors that can be improved through education. It can include the following topics:

· Information about pregnancy and physical changes that occur during pregnancy

· Normal changes due to pregnancy (specific to trimester)

· Anatomy and physiology related to pregnancy

· Fetal development

· Emotional and psychosocial concerns

· Description and importance of continued prenatal care

· Comfort measures

· Self-care during pregnancy

· Pregnancy danger signs

· Specific medical conditions

· Diagnosis and significance of condition during pregnancy

· Treatments including medications, activity level, options and rationale

· Appropriate referrals

· Information to prepare the pregnant person for the birth process when they are near the end of the second trimester or early third trimester:

· Anatomy and physiology of labor and delivery

· Coping skills

· Medical management

· Hospital procedures

· Danger signs

· Communication with health providers

· Information that helps the pregnant person identify and take steps to prevent preterm labor and delivery includes the following:

· Symptoms of preterm labor

· Self-detection of preterm labor

· Treatment

· Preventive measures

Prenatal Health Education II: Lifestyle and Parenting Support (H1003)
Lifestyle and Parenting Support educational services supplement the Prenatal Health Education I services; and are necessary for a pregnant person who requires more time and specialized education to promote a healthy pregnancy lifestyle. Lifestyle changes resulting from this early and consistent education may have long-term impacts on improving the health of the pregnant person, baby and subsequent pregnancies.

Topics addressed in Prenatal Health Education II will depend on the individual needs of the high-risk pregnant person. They may include the following topics:

· Education on the effects of smoking, alcohol, and other substances on birthing people and fetal development

· Smoking, alcohol, and other substance cessation or harm reduction education

· Referral to a support program

· Education on safe use of over-the-counter (OTC) medications and prescription drugs including the need to consult with their provider before using any type of medication during pregnancy

· Environmental and occupational hazards (for example, lead)

· Identify potential exposure to hazard in the birthing person’s own environment

· Effects on fetal growth and development

· Efforts to minimize exposure

· Referrals for follow-up if needed

· Stress management

· Identification of potential stressors in the person’s life: job, unemployment, school

· Self-identification of signs of stress

· Relaxation techniques

· Referral to support services when appropriate

· Coping skills

· Communication skills and resources

· Family support systems

· Health care providers

· Building self-esteem

· Parenting skills to meet the physical, emotional and intellectual needs of the infant; bonding

· Identification and affirmation of positive prenatal parenting

· Infant needs and cares

· Nurturing

· Infant feeding preparation

· Referral to community resources if needed

· Planning for continuous, comprehensive pediatric care following delivery

Documentation Requirements for Prenatal Health Education I and II
Documentation requirements include: Evidence that education, information, or both was provided, amount of time spent, materials used, notes about the person’s reactions to information, review of information at subsequent visits, dates and people providing the service, referrals and follow-up.

Prenatal Nutrition Education (H1003)
Prenatal Nutrition Education includes nutritional assessment and education that identifies nutritional risks and problems that the pregnant person may already have or be in danger of developing. Develop an individualized nutrition care plan for each “high-risk” pregnant person based on the assessment of their nutritional status, and address the prevention and resolution of identified risks and problems. Incorporate the nutrition care plan into the overall individualized plan of care.

Nutrition interventions include individual or group (or both) nutrition education, and provide information that will assist the pregnant person in making informed nutritional choices.

Prenatal Nutrition Education includes the following:

· An initial assessment of “nutritional risk” based on height, current and pre-pregnancy weight, laboratory data, clinical data and self-reported dietary information

· Ongoing assessment of the pregnant person’s nutritional status (at least once every trimester) based on dietary information, measures to assess uterine and fetal growth, laboratory data and clinical data

· Development of an individualized nutrition care plan that addresses the person’s nutritional needs, and proposes interventions and time frames with expected outcomes

· Referral to food assistance programs if indicated (WIC, food support, Mothers and Children Program or similar programs)

· Nutritional interventions and education including:

· Nutritional requirements of pregnancy and how nutrition is linked to fetal growth and development

· The nutritional needs of the baby during pregnancy

· Recommended weight gain for pregnancy

· Importance of vitamin and iron supplements and recommendations for taking them

· Infant nutritional needs and feeding practices, including the benefits of breast feeding

· Incorporation of prenatal and postnatal exercise and physical activity when not contraindicated

Documentation Requirements for Prenatal Nutrition Education
Documentation requirements include:

· A written assessment of the person’s nutritional status, and evidence of ongoing assessment and monitoring of their nutritional status

· A written, individualized nutritional care plan indicating proposed interventions, time frames, expected outcomes and evidence of monitoring and ongoing evaluation of the care plan

· Evidence that education and information on nutrition was provided, materials used, amount of time spent, notes about the person’s reactions to the information, review of information at subsequent visits, dates and people providing the service, referrals and follow-up

Postpartum Follow-up Home Visit (H1004)
The postpartum follow-up home visit, is in addition to and separate from the member’s six-week postpartum visit to their primary care provider. It is to be completed within the first two weeks of the member’s hospital discharge.

This visit gives special support to high-risk members and infants by following up on identified high-risk behaviors or medical conditions, and addressing the stress involved in caring for a new baby. It is an opportunity to provide:

· Reinforcement and support for positive parenting skills

· Family planning counseling

· Anticipatory guidance for healthy parenting

· Education about infant care

The home visit assesses any needs of the family that will require additional home visits or referrals to appropriate health and social service providers. Services include the following:

· Assessment of the member’s health

· Follow-up on risks and medical conditions

· Reinforcement of positive lifestyle changes

· Physical and emotional changes occurring during the postpartum period

· Anticipatory guidance regarding relationship with partner

· Sexuality

· Potential stress with family

· Nutritional needs

· Physical activity and exercise

· Contraceptive education

· Parenting skills and support

· Adapting to parenthood

· Parent and child relationship; bonding

· Child care arrangements and support

· Grief support if unexpected outcome

· Parenting a sick or preterm infant, if indicated

· Follow-up on risk factors and conditions

· Assessment of infant’s health

· Infant weight and growth

· Infant development and abilities

Documentation Requirements for Postpartum Follow-up Visit
Documentation requirements include the following:

· Written assessment of member’s and infant’s health and the home environment

· Documentation that education or information on nutrition was provided and evidence of the materials used, amount of time spent, notes about the member’s reactions to the information, review of information at subsequent visits, dates and people providing the service, referrals and follow-up

· Documentation of all referrals made, and follow-up on those referrals

· Infant care

· Feeding and infant nutritional needs

· Recognition of illness in the newborn

· Accident and injury prevention

· Immunizations and pediatric care

· Child and Teen Checkups (C&TC)

· Identification and referral of community health and social service resources and assessment of need for additional home visits for either the birthing person or infant

Screening Ultrasound in Uncomplicated Pregnancy
The Minnesota Department of Human Services allows a single screening ultrasound (ideally conducted at 16-20 weeks gestation) per pregnancy to evaluate gestational age and anatomy, detect multiple pregnancies and to evaluate potential abnormalities. Additional diagnostic ultrasounds are covered only as medically necessary. Indications supporting medical necessity for additional ultrasounds include, but are not limited to, the following:

· Abnormal pregnancy serum analytes

· Adjunct to:

· Amniocentesis, chorionic villus biopsy, fetal blood sampling

· Cervical cerclage placement

· External cephalic version

· Localization and removal of an intrauterine contraceptive device

· Special diagnostic or therapeutic procedures on the fetus

· Completion of anatomical screen for inadequate visualization of fetal organs

· Confirm fetal viability or fetal death

· Diabetes or gestational diabetes

· Diagnosis of Zika Virus

· Evaluation of:

· A pelvic mass

· Incompetent cervix or risk of preterm delivery

· Fibroid uterus

· Follow-up of observed fetal anomaly

· History of previous congenital anomaly

· Hyperemesis

· Hypertension, essential and pregnancy induced

· Identification and follow-up of placenta previa

· Nonreactive nonstress test

· Post-term pregnancy

· Rh sensitization or isoimmunization

· Serial evaluation of fetal growth in multiple gestation

· Significant uterine size and dates discrepancy

· Suspected:

· Abruptio placentae

· Ectopic pregnancy

· Hydatidiform mole

· Oligohydramnios or polyhydramnios

· Uterine abnormality

· Vaginal bleeding

Pregnancy Health Education

Pregnancy health education (prenatal) classes are covered for all pregnant members, not just those at high-risk for adverse birth outcomes.

Eligible providers may provide and bill for prenatal education classes. Eligible providers include the following:

· Enrolled physicians

· Nurse practitioners

· Physician assistants

· Clinical nurse specialists

· Certified professional midwives

· Certified nurse midwives

Additionally, clinics and outpatient hospitals where prenatal education program is directed by one of the enrolled providers, may bill for registered nurses or health educators with at least a baccalaureate-level degree in health education or certification for prenatal education, or both, from one of the following organizations:

· International Board of Lactation Consultant Examiners (IBLCE)

· International Childbirth Education Association (ICEA)

· Lamaze

· National Commission for Health Education Credentialing (NCHEC)

Lactation

MHCP covers lactation consultations and classes as a preventative care service during pregnancy and up to 12 months postpartum.

Lactation consultations can be provided by certified lactation counselors, Indigenous lactation counselors, International Board-Certified Lactation Consultants, and other health care professionals whose scope of practice includes lactation education.

Lactation classes can be provided by a certified lactation educator, certified lactation counselors, Indigenous lactation counselors, International Board-Certified Lactation Consultants, or other health educators with training in lactation.

Breast pumps and accessories are also a covered service. One electric breast pump is covered per pregnancy. Refer to Breast Pumps under the Equipment and Supplies section in the MHCP Provider Manual for more details. Pasteurized donor human milk is covered for babies with a medical need when they don’t have another way to receive breast milk. Refer to Nutritional Products and Related Supplies under the Equipment and Supplies section in the MHCP Provider Manual for more details.

Physician Standby Attendance for Newborn
MHCP will cover a pediatric standby when there is fetal distress. The following examples of fetal distress may warrant a pediatric standby:

· Fetal bradycardia

· Diabetes in the birthing person

· Meconium

· Premature labor

· Foul-smelling amniotic fluid

· Birthing person taking certain medications

If the pediatrician bills for standby services, thoroughly document the reason the pediatrician provided services to the infant. Conditions such as pronged labor, failure to progress and cephalopelvic disproportions are generally not reasons for billing physician standby services unless fetal distress is also a factor.

HIV Counseling and Testing for Pregnant People

MHCP follows the recommendations of the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Minnesota Department of Health that advocate HIV testing for all pregnant people.

MHCP recommends that all pregnant members receive screening, education, counseling and voluntary testing for HIV at the first prenatal visit to ensure timely and therapeutic reproductive decision making. Advances in the treatment of HIV infection, and progress in reducing the transmission of HIV infection to newborns, makes early intervention crucial.

HIV screening, education, counseling and testing is reimbursed in addition to routine prenatal care. Physician extenders may provide HIV counseling to pregnant people within their scope of practice.

Keep a consent form or passive consent notification for HIV testing in the medical record. If the member refuses HIV testing after counseling, document the refusal in the medical record. Counseling, screening and education for HIV will be reimbursed if provided, whether or not the member consents to have HIV testing. Testing will be reimbursed when consent is given and the testing is complete.

Inform HIV positive pregnant people of their treatment options and of the related HIV services that are available. Call the Program HH office at 651-431-2414 or 800-657-3761 for more information.

Voluntary testing is when a member consents to HIV testing after they have received pretest counseling, is informed of their right to refuse HIV testing, is informed that their refusal will not jeopardize their health benefits, and does not refuse the testing.

Pre-test counseling includes the following components:

· Explanation of HIV

· Risk factors for HIV infection and how the virus is transmitted

· Treatment available for HIV-positive member during pregnancy and after delivery

· Risk factors for the newborn

· Treatment options for the newborn

· Rights of the pregnant person to choose testing

· Explanation of who has access to test results and confidentiality

· HIV risk assessment

Post-test counseling includes the following components:

· Give and explain test results

· Risk factors for HIV infection and how to reduce the risk of infection

· If HIV test results are positive, referrals for additional services and information about treatment options

· Information about how the virus is transmitted and how to reduce the risk of transmission

· If HIV test results are positive, counseling and referrals related to health issues for partners and children that may have been infected

· Information about the need for repeat follow-up testing whether the results are positive or negative

· Referral for case management services for HIV-positive members and their newborns

· Referral to local community support services such as Minnesota AIDS Line

· Informed Consent: The member received the following information:

· That HIV testing is voluntary

· The entities who have access to HIV test results (such as third party payers or public health agencies)

· When, and under what circumstances, this information can be released (such as a legal subpoena)

Confidentiality includes documentation indicating that HIV test results are private. Confidential HIV information can be released only to individuals or entities with the written permission of the member. You must inform the member about the law that allows the release of the HIV test results (without permission) under limited circumstances.

Positive test is a test result that is positive for the HIV antibody.

Negative test is a test result that is negative for the HIV antibody. Additional follow-up testing, especially for members with known recent HIV exposure or with continued risk behaviors, may be needed to determine recent infection.

Follow-up health services provided to HIV-positive members and their infants must include:

· Review of what it means to be HIV positive (it does not mean that they have AIDS, but it does mean they can infect others).

· Ongoing lab tests to evaluate immune system function

· Ongoing counseling regarding HIV status and treatment options

· Emphasis on the need for good health practices

· Information about current treatment practices to reduce the risk of transmission of HIV and to promote the health of the member

· Information that a positive HIV test result can mean that children and partners could be infected with HIV and that those individuals must be referred for medical testing and follow-up

· Information that a baby born to an HIV-positive member must receive regular medical care from a physician who is knowledgeable about HIV treatment to ensure appropriate care

· Information that all babies are born with the birthing person’s antibodies and many months of follow-up are required to determine the newborn’s HIV status. If a baby is not infected, the HIV test will be negative by 18–24 months

· Discussion with people who are breast feeding or considering breast feeding of the risk of transmission of HIV through breast feeding (the CDC recommends that HIV positive people not breast feed)

· Emphasize that HIV is not spread through casual contact

Noncovered Services

MHCP does not cover services related to surrogate pregnancies.

Telehealth Services

Telehealth services are covered for MHCP members. Providers must submit a completed and signed Telehealth Provider Assurance Statement (DHS-6806) (PDF) to the Minnesota Department of Human Services to bill for telehealth services. Review Telehealth Services in the MHCP Provider Manual for more information.

Billing

Refer to Billing Policy Overview and Provider Requirements under the Provider Basics section in the MHCP Provider Manual for general billing information.

Bill electronically using the MN–ITS 837P

Enhanced Services for High-risk Pregnancies

· Enhanced services will be paid only for a high-risk pregnant person (high-risk status must be established by prenatal screening)

· Primary care providers may contract or refer the enhanced services to other MHCP-enrolled providers. Enrolled providers performing the service directly bill MHCP.

Billing for Enhanced Services

Enhanced Services	HCPCS Code	Providers Authorized to Provide Service and Bill
At-risk Antepartum Management	H1001	MD, DO, CNM, CPM
Care Coordination	H1002	MD, DO, CNM, CPM, CNP, CNS, PA, RN
Prenatal Health Education I	H1003	MD, DO, CNM, CPM, CNP, CNS, PA, RN, Health Education Professional*
Prenatal Health Education II	H1003	MD, DO, CNM, CPM, CNP, CNS, PA, RN, Health Education Professional*
Prenatal Nutrition Education	H1003	MD, DO, CNM, CPM, CNP, CNS, PA, RN Dietitian, Nutritionist
Postpartum Follow-up Home Visit	H1004	MD, DO, CNM, CPM, CNP, CNS, PA, RN
* Health educators with at least a baccalaureate-level degree in health education or certification for prenatal education from one of the following organizations: ICEA, Lamaze, NCHEC or IBLCE. ** Providers authorized to perform service with documented specialized nutritional education.

Pregnancy Health Education

· Do not bill for classes that are provided free to non-MHCP members

· Use HCPCS codes S9442 for birthing classes. Bill one unit for each class encounter. A class that meets once a week for three weeks has three encounters.

· Public health nursing clinics may bill for pregnancy health classes, or other group education, using S9446. Bill one unit per member for each class encounter. A class that meets once a week for three weeks has three encounters.

Lactation Billing:
Bill HCPCS code S9443 to bill for lactation classes. Bill one unit for each class encounter. Example: A class that meets once a week for three weeks has three encounters. For lactation consultations, bill the appropriate code and place of service for each consultation.

HIV Services for Pregnant People

· Bill for HIV screening, education, counseling and testing in addition to routine prenatal care using the appropriate CPT codes.

· Physician extenders must use the appropriate modifier.

Obstetric Services
Obstetric care can be billed either globally or by components. The billing method used is the provider’s choice, but only one method can be used for each obstetric case. Follow CPT guidelines for global and component billing.

· Do not bill the CPT obstetric panel code unless all components of the laboratory panel are performed.

· If all components of the panel are not performed, bill the individual laboratory procedure codes you have CLIA approval to bill. Refer to the Laboratory/Pathology, Radiology & Diagnostic Services section of the MHCP Provider Manual.

· Miscellaneous services (for example, amniocentesis, ultrasound, fetal non-stress test, fetal Fibronectin, oxytocin challenge, estriol) must be billed with the appropriate codes.

· Bill pregnancy and non-pregnancy related services on separate invoices using appropriate ICD-CM diagnoses.

· When billing the global bundle code, bill any services above and beyond a routine pregnancy separately from the bundle.

· Bill vaginal delivery of multiple gestation births using modifier 22 with the appropriate CPT procedure code.

· Bill Cesarean section done in response to an emergency using the ET modifier with the appropriate CPT procedure code.

· Bill newborn services using the newborn’s MHCP ID number and date of birth. This includes routine newborn care and any inpatient services to the newborn, whether before or after the birthing person’s discharge.

· Bill the birthing person’s services using the birthing person’s MHCP ID number.

· Refer to Inpatient Hospital Authorization for billing instructions when a newborn is transferred to another facility for specialty services

· MHCP covers male circumcision only when the procedure is medically necessary

· MHCP will deny claims that do not contain a valid birth weight. Refer to the Inpatient Hospital Services section of the MHCP Provider Manual for birth weight requirement.

· Long-acting reversible contraceptives are billable outside of the hospital labor and delivery bundle.

Definitions

High-risk is used to describe a pregnant person who requires additional prenatal care services because of factors that increase the probability of a preterm delivery, a low birth weight infant or an adverse birth outcome.

Certified Nurse Midwife Practice: The management of member’s primary health care including pregnancy, childbirth, postpartum period, care of the newborn, family planning, partner care management relating to sexual health, and gynecological care of women across the lifespan. Their scope of practice includes ordering, performing, supervising, and interpreting most diagnostic studies, prescribing pharmacologic and nonpharmacologic therapies; and consulting with, collaborating with, or referring to other health care providers as warranted by the needs of the patient.

Certified Nurse Practitioner Practice: Nurse practitioner practice means the provision of care including: health promotion, disease prevention, health education, and counseling. It includes providing health assessment and screening activities as well as diagnosing, treating, and facilitating patients’ management of their acute and chronic illnesses and diseases. Their scope of practice includes ordering, performing, supervising and interpreting most diagnostic studies as well as prescribing pharmacologic and nonpharmacologic therapies; and consulting with, collaborating with, or referring to other health care providers as warranted by the needs of the patient.

Enhanced Services are services available to members identified as at-risk for a poor pregnancy outcome. These services are reimbursed in addition to routine obstetric services. Enhanced services include at-risk antepartum management, care coordination, prenatal health education I and II, prenatal nutrition education and postpartum follow-up home visit.

Low Birth Weight is a birth weight less than 2,500 grams (5.5 pounds).

Preterm Birth is a birth before the gestational age of 38 weeks.

Risk Assessment is a standardized prenatal assessment tool, or equivalent, for identification of the medical, genetic, life-style, and psychosocial factors that put a member “at-risk” for preterm delivery, a low birth weight infant, or a poor birth outcome.

Legal References

Minnesota Rules 9505.0320 (Nurse Midwife Services)
Minnesota Rules 9505.0353 (Prenatal Care Services)
Minnesota Statute 147D (Traditional Midwives)
Minnesota Statute 148.171 – 141.285 (Minnesota Nurse Practice Act)
Minnesota Statute 256B.0625, subdivision 13 (Drugs)
Minnesota Statute 256B.0625, subdivision 14 (Diagnostic, screening, and preventative services)
Minnesota Statute 256B.756, subdivision 1 (Reimbursement Rates for Births)
Code of Federal Regulations, title 42, section 440.130 (Diagnostic, screening, preventative, and rehabilitative services)
Code of Federal Regulations, title 42, section 440.165 (Nurse-midwife services)
Code of Federal Regulations, title 42, section 441.21 (Nurse-midwife services)

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