Partnership Healthplan Of California Medi-Cal Provider Manual Claims Department (Page 2 of 3) in pdf

* These codes must be billed with an outcome of delivery as one of the diagnosis.

Outcome of delivery codes 650. or V27.0 – V27.7 must be one of the diagnosis

billed.

# These codes must be billed with:

1. An outcome of delivery as one of the diagnosis billed.

2. In the “from-through” billing format (called “from-to” on the CMS 1500 claim

form) with modifier AG. The “from” DOS is the first date the member was seen

for this pregnancy, and the “through” or “to” date of service is the date of the

delivery.

3. A minimum of four prenatal visits listed in the Remarks area/Reserved for Local

Use field (Box 19) or on an attachment. (The member must be eligible for at least

a minimum of four visits.)

** New PHC Policy on Prenatal Visits

Partnership HealthPlan recognizes that some pregnant patients need more than 10

prenatal visits, for medical reasons. See the State MediCal Manual for documentation

requirements for standard prenatal visits (codes used for first visit, tenth visit, second

through 9

visit, post-partum visit). This explains documentation requirements and

standards for submitting claims for more than 10 prenatal visits. It does not apply to

office visits for non-obstetrical problems that occur during pregnancy.

Effective for dates of service on or after August 1, 2012:

1. Additional visits with no TAR requirements: Patients requiring 11-15 prenatal

visits (using Z1034) for medically necessary reasons, may have those claims paid

without submission of a TAR.A provider may not use both a global OB billing

code and bill for individual prenatal visits. Since the initial OB visit and the tenth

OB visit use different codes, this means that Z1034 may be billed up to 13 times

without a TAR form.

2. Examples of Medical Necessity: Medical Necessity includes early onset of

prenatal care, threatened miscarriage, pre-term labor, hyperemesis, pre-eclampsia,

diabetes during pregnancy or other complications of pregnancy requiring more

frequent visits. The diagnosis code for the reason for Medical Necessity must be

included in claims submitted. Early entry into prenatal care has no exact ICD9

code; V22.2 may be used with a notation in the comments field “early entry into

prenatal care, initial visit date: ______”

3. TAR requirements: A TAR is required for prenatal visits beyond 15. The TAR

form and instructions for completing the TAR can be found on the Partnership

HealthPlan website:

PHC Medi-Cal Provider Manual – Section 3, Sub-section X.L.

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Partnership Healthplan Of California Medi-Cal Provider Manual Claims Department Page 2