Ala. Admin. Code r. 560-X-21-.05

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-21-.05 - Covered Services

(1) The maternity services normally provided in maternity cases include antepartum care, delivery, and postpartum care. When a nurse midwife provides total obstetrical care, the procedure code which shall be filed on the claim form is the code for all inclusive "global" care. The indicated date of service on "global" claims should be the date of delivery. If a woman is pregnant at the time she becomes eligible for Medicaid benefits, only those services provided during the time she is eligible will be covered. When a nurse midwife provides eight (8) or more prenatal visits, performs the delivery, and provides postpartum care, he/she shall use a "global" obstetrical code in billing the services. If a nurse midwife submits a "global" code for maternity services, the visits covered by this code are not counted against the recipient's limit of physician office visits per calendar year. For purposes of "global" obstetrical billing, services rendered by members of a group practice are to be considered as services rendered by a single provider.

(a) Antepartum care includes all usual prenatal services such as initial office visit, at which time the pregnancy is diagnosed, initial and subsequent histories, physical examinations, blood pressure recordings, fetal heart tones, maternity counseling, etc.; therefore, additional claims for routine services shall not be filed. Antepartum care also includes routine lab work (i.e.; hemoglobin, hematocrit, and chemical urinalysis); therefore, additional claims for routine lab work should not be filed.

1. In order to bill for Antepartum Care Only services, nurse midwife providers must utilize the antepartum procedure codes when billing for the services. Antepartum Care Only services do not count against the recipient's annual office visit benefit limits. When less than four antepartum visits are provided, the nurse midwife will use office visit procedure codes to bill for the services. The office visit procedure codes will be counted against the recipient's annual office visit benefit limit.

(b) Delivery shall include vaginal delivery (with or without episiotomy) and postpartum care or vaginal delivery only services. The nurse midwife will utilize the appropriate CPT code when billing delivery services. More than one delivery fee may not be billed for a multiple birth (i.e.; twins, triplets, etc.). Delivery fees include all professional services related to the hospitalization and delivery services provided by the nurse midwife. Additional claims for the nurse midwife's services in the hospital (e.g., admission) may not be filed.

EXCEPTION: When a nurse midwife's first and only encounter with the recipient is for delivery ("walk-in" patient) he/she may bill for a hospital admission (history and physical) in addition to delivery charges.

(c) Postpartum care includes office visits following vaginal delivery for routine postpartum care within sixty (60) days post delivery. Additional claims for routine visits during this time should not be filed.

(2) Family planning services include services that prevent or delay pregnancy such as office visits for evaluation and management of contraceptive issues, including procedures and supplies as appropriate for effective birth control. Nurse midwives are not authorized to do sterilization procedures. Other surgical procedures; such as diaphragm fittings, IUD insertions or removals, and contraceptive implant procedures; are covered when provided according to state laws and regulations.

(3) The nurse midwife may provide and be reimbursed for well-woman gynecological services including the evaluation and management of common medical and/or gynecological problems such as menstrual problems, Pap smear screening, menopausal and hormonal treatments, treatment of sexually transmitted diseases, and treatment of minor illnesses (e.g., a minor pelvic inflammatory disease).

Author: Glen A. Smythe

Ala. Admin. Code r. 560-X-21-.05

Emergency rule June 14, 1993. Effective August 12, 1993. Amended: Filed February 7, 1994; effective March 15, 1994. Amended: Filed July 6, 1995; effective August 12, 1995.

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R., §§440.165, 440.210, 440.220, 441.21; Code of Ala. 1975, §§ 34-19-2, etseq.