Pregnancy Care Office Visit: Antepartum Initial
Date: | July 10, 2024 |
From: | Health Plan |
To: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Obstetric Care Providers |
Type: | Regulatory |
Subject: | Pregnancy Care Office Visit: Antepartum Initial |
Business: | Medi-Cal Managed Care |
Please review the following Medi-Cal (MCL) billing guidelines for proper claim submission and reimbursement for initial antepartum visits.
Pregnancy Care Office Visit: Antepartum Initial
Initial pregnancy-related office visit (HCPCS code Z1032) is the first prenatal visit and is billed after the pregnancy has been confirmed. This code is comparable to a high-complexity Evaluation and Management (E&M) code and must include a comprehensive history, physical examination, and medical decision-making of high complexity. If these components are not performed and documented in the medical record, antepartum follow-up office visit (HCPCS code Z1034) should be billed.
When billing HCPCS Z1032, one of the following pregnancy-associated diagnosis codes must be used: O09.00 thru O26.93, O29.011 thru O48.1, O98.011 thru O9A.519, Z34.00 thru Z34.93.
The following billing guidelines apply:
- Z1032 may be billed separately in conjunction with per-visit or global care
- Limit to once in six months per provider, unless care is transferred to another physician during the same pregnancy, or the provider certifies in the Additional Claim Information field (Box 19) that pregnancy has recurred within a six-month period.
- Indicate date of transfer or date of fetal demise and document in the Additional Claim Information field (Box 19).
Pregnancy Co-Management
Consultants who co-manage a pregnancy without complete transfer of care should not bill with HCPCS code Z1032. Instead, E&M consultation codes 99242 thru 99245 should be used.
Only primary obstetrical providers are to bill codes Z1032 and Z1034. All other providers must bill with E&M consultation codes 99242 thru 99245.
Per Visit Policy
A provider who does not render total obstetrical care during the recipient’s entire pregnancy or who renders fewer than 13 antepartum visits must bill each visit or procedure separately. The initial pregnancy-related office visit (Z1032) may not be counted as one of the 13 visits. Each visit is subject to the six-month billing limit, and recipient eligibility must be verified for each month of service.
For additional information related to obstetrics service billing, please see: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/09FC6B68-5741-4478-B087-2D8CA5DBAC25/workbook_ob_hap.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG