A suitable timeline for prenatal and postpartum careTexas Children's Health Plan
Timely prenatal and postpartum care is an important component of successful health outcomes for women and their babies, as well as a measure of quality care.
The first prenatal visit must be rendered in the first trimester or during the first 42 days of enrollment into the health plan to meet the standards set forth by Healthcare Effectiveness Data and Information Set (HEDIS).
In order for the visit to qualify as a postpartum visit, it must include documentation in the chart showing the date of the visit and ONE of these 3 services:
- Pelvic exam OR;
- Weight evaluation, blood pressure, breast, and abdomen exam (if there is no breast examination, notation of breastfeeding education is acceptable) OR;
- Notation of postpartum care, including but not limited to the following:
- Notation of “postpartum care,” “PP care,” “PP check,” or “6-week check”.
- A preprinted “Postpartum Care” form in which information was documented during the visit.
The postpartum visit must be rendered within the specified HEDIS timeline of 21 to 56 days after delivery.
- Providers need to bill with the CPT code 59430 on the claim form.
- Only one postpartum visit is required during the 21 to 56 days after delivery (using the 59430 code).
- Any additional visits that may be needed from Day 1 to Day 56 should be billed with E/M visit codes. This includes visits that occur 1 to 20 days after delivery, which should be billed utilizing E/M codes on the claim form (e.g. C-section incision, episiotomy, blood pressure check, mastitis, etc.).