Provider Alert! Ensuring Timely Prenatal and Postpartum Visits Reminder
Date: May 17, 2023
Attention: Obstetric Care Providers
Call to action: Texas Children’s Health Plan (TCHP) encourages OB/GYNs and other providers to take measures to ensure that your patients, our members, are receiving timely prenatal and postpartum visits. TCHP is committed to optimizing the quality of obstetric care provided to members during pregnancy and the postpartum period. Together, we can support healthy pregnancies, reduce maternal mortality and improve neonatal outcomes.
OB/GYNs and other providers are encouraged to share this communication with their staff and implement office management protocols that prioritize scheduling of timely prenatal and postpartum appointments.
Early Prenatal Care and Timely Postpartum Care
Providing early prenatal care, starting in the 1st trimester:
- is a recognized quality metric
- promotes healthy pregnancy outcomes
- optimizes the potential for early recognition and intervention for high risk maternal and fetal conditions
Postpartum care tailored to the needs of the member:
- between 7 and 84 days is a recognized quality metric
- is recommended within the first 3 weeks after delivery, followed by ongoing care as needed
- note: currently, Medicaid coverage will term at 60 days after delivery
How TCHP Supports Members
TCHP is working to:
- educate on the importance of timely, consistent care during pregnancy, postpartum and in the fourth trimester
- identify and address barriers to care
- assist with care navigation including appointment scheduling, transportation, referrals and care coordination
Partnership for Quality Care
TCHP encourages OB/GYNs and other providers to partner with us to emphasize the importance of care before and after birth and accommodate scheduling timely care for all patients. Thoughtful consideration of innovative models of care including group prenatal care and hybrid models integrating telemedicine where clinically appropriate may increase access to care and member satisfaction.
Potential Provider Incentives: In order to assist and recognize providers who ensure our members receive timely, quality prenatal and postpartum care, providers may be eligible to participate in a Provider Incentive Program. Providers must qualify to participate in this program based on their panel size and network participation. If you are interested in learning more, please contact your assigned Provider Relations Liaison (PRL). If you are not aware of your assigned PRL, please email providerrelations@texaschildrens.org. We are excited to offer this to our network and encourage your participation.
How this impacts OB/GYNs and other providers:
TCHP asks providers to please:
- schedule all required appointments in accordance with recommendations for quality obstetric care
- prioritizing individual member needs including but not limited to clinical risk factors and gestational age
- submit all claims timely, as soon as services are rendered
- use the appropriate codes on your claims to reflect the services provided, particularly for prenatal and postpartum visits
TCHP would like OB/GYNs and other providers to be aware that we actively assist members who fall behind or are in need of prenatal or postpartum care. With expressed member consent, TCHP Field Relation Coordinators (FRCs) overcome barriers to care by:
- facilitating appointment scheduling with member’s selected provider
- assist with transportation or other needs a member may encounter that prevents them from keeping their appointment. Click here for information on member transportation services.
Next steps for providers: We kindly ask that OB/GYNs and other providers submit claims timely so that they are compliant with the Healthcare Effectiveness Data and Information Set (HEDIS) measures. In doing so, you’re continuing to provide great care to our members while also having the opportunity to participate in the Provider Incentive Program. We ask that providers use appropriate codes to reflect the services for prenatal and postpartum visits. Additional information on appropriate coding is shown below:
Timeliness of prenatal care (TOPC):
The percentage of deliveries that received a prenatal care visit in the first trimester, on or before the enrollment start date, or within 42 days of enrollment.
| CPT codes (new patients) | 99201, 99202, 99203, 99204, 99205 |
| CPT codes (established patients) | 99211, 99212, 99213, 99214, 99215 |
| HCPCS | T1015 |
| ICD-10 diagnosis codes | Z34.-___* OR O09.- to O99.-___ † |
* codes for supervision of normal pregnancies.
† codes for supervision of conditions affecting pregnancy
Postpartum care (PPC):
The percentage of deliveries that had a postpartum visit on or between 7 to 84 days after delivery.
Note: Medicaid coverage will term at 60 days after delivery.
| CPT codes | 59430* |
| CPT-CAT-II codes | 0503F |
| ICD-10 diagnosis codes | Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2 |
* 59430 is reimbursable once per pregnancy by Texas Medicaid and must be used for a visit between 7-60 days. Subsequent postpartum visits must be billed using E&M codes. Visits solely for staple removal do not qualify for use of 59430.
NOTE: Both CPT and appropriate ICD-10 codes must be present for claim to be paid.
Click here to view the HEDIS toolkit available for guidance on providing and coding for quality prenatal and postpartum care.
For additional information on the importance of prenatal and postpartum visits, and information to share with patients, providers and staff can visit:
ACOG Optimizing Postpartum Care
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
