CurrentAlabama MedicaidPolicy N/A

Nurse Midwife Program — Coverage Criteria for Certified Nurse Midwives

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Rules governing participation, covered services, billing, reimbursement, and record requirements for certified nurse midwives participating in the Alabama Medicaid program.

Policy Summary

PayerAlabama Medicaid

PolicyNurse Midwife Program — Coverage Criteria for Certified Nurse Midwives

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 1982

Last ReviewMar 15, 1994

Next Review DateN/A

Key ActionEnsure nurse midwives are enrolled, approved, under contract, and issued a provider number before billing Medicaid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8+ visitsGlobal maternity billing rule

59425/59426Antepartum-only codes

60 daysPostpartum window

RN & CNMProvider qualification

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CurrentAlabama MedicaidPolicy N/A

Nurse Midwife Program — Coverage Criteria for Certified Nurse Midwives

Customize your policy alerts

Sign up for all Alabama Medicaid policy alerts

Know when Alabama Medicaid releases new policies or updates existing guidance.

Monitor payer policy activity

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Rules governing participation, covered services, billing, reimbursement, and record requirements for certified nurse midwives participating in the Alabama Medicaid program.

Policy Summary

PayerAlabama Medicaid

PolicyNurse Midwife Program — Coverage Criteria for Certified Nurse Midwives

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 1982

Last ReviewMar 15, 1994

Next Review DateN/A

Key ActionEnsure nurse midwives are enrolled, approved, under contract, and issued a provider number before billing Medicaid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8+ visitsGlobal maternity billing rule

59425/59426Antepartum-only codes

60 daysPostpartum window

RN & CNMProvider qualification

Covered Maternity and Related Services

Covered maternity services and billing rules

Global maternity services: When a nurse midwife provides total obstetrical care (antepartum care, delivery, and postpartum care) and provides eight (8) or more prenatal visits, the midwife shall bill using an all-inclusive 'global' obstetrical code; the indicated date of service for global claims must be the date of delivery.8 prenatal visits

Visits covered by the global code are not counted against the recipient's annual physician office visit limit. For group practices, services rendered by members of the group are considered services rendered by a single provider.

Antepartum-only billing: Antepartum Care Only may be billed using CPT 59425 for four to six visits or CPT 59426 for seven or more visits. Nurse midwives who provide fewer than four antepartum visits must bill using office visit procedure codes.<4 visits -> office visit codes

Antepartum-only services billed with 59425/59426 do not count against the recipient's annual office visit benefit limits; office visit codes will count against annual limits.

Delivery billing: Delivery services (including vaginal delivery with or without episiotomy and postpartum care or vaginal delivery only) must be billed with the appropriate CPT delivery code. Only one delivery fee may be billed per multiple birth. Delivery fees include all professional hospital services related to hospitalization and delivery; additional hospital service claims by the midwife (e.g., admission) may not be filed except for the 'walk-in' delivery exception.N/A

Exception: if the midwife's first and only encounter is delivery ('walk-in' patient), the midwife may bill for a hospital admission (history and physical) in addition to delivery charges.

Postpartum services: Postpartum care includes routine visits for postpartum care within sixty (60) days post delivery; these routine visits are included in the global/postpartum service and additional claims for routine visits during this time should not be filed.<=60 days post delivery

Family planning services performed by the delivering provider on the day of the postpartum exam or within five (5) days of the postpartum exam are noncovered as separate services because they are included in the postpartum exam. If the provider did not perform the delivery but provides postpartum care, family planning services rendered within five (5) days of the postpartum exam are also noncovered.

Family Planning and Well-Woman Care

Family planning and gynecological services

Family planning services that prevent or delay pregnancy (office evaluation and management, procedures, and supplies) are covered when provided according to state law and regulations. Nurse midwives are not authorized to perform sterilization procedures.N/A

Diaphragm fittings, IUD insertion/removal, and contraceptive implant procedures are covered when performed according to state law and regulations. Medicaid recipients are exempt from co-payment requirements for family planning services.

Well-woman gynecological services: Nurse midwives may provide and be reimbursed for well-woman gynecological services, including evaluation and management of common gynecological problems (e.g., menstrual problems), Pap smear screening, menopausal and hormonal treatments, treatment of sexually transmitted diseases, and treatment of minor gynecologic illnesses.N/A

Co-pay requirements apply to well-woman gynecological office services except for recipients under age 18.

Family planning services include evaluation and management visits, procedures, and supplies that prevent or delay pregnancy and are covered when provided according to state law. Nurse midwives are not authorized to perform sterilization procedures; other contraceptive services such as diaphragm fittings, IUD insertion/removal, and contraceptive implant procedures are covered when performed in accordance with applicable laws and regulations. Routine well-woman gynecological services (Pap screening, menopausal/hormonal treatments, STI treatment, and treatment of minor gynecologic illnesses) are reimbursable when provided by a nurse midwife.

Postpartum care is considered part of the delivery episode and includes routine visits within 60 days post delivery. Family planning services performed by the delivering provider on the day of the postpartum exam or within five (5) days of the postpartum exam are noncovered because they are included in the postpartum exam. If the midwife did not perform the delivery but provides postpartum care, family planning services rendered within five (5) days of the postpartum exam are likewise noncovered.

A provider may bill a Medicaid recipient for any noncovered service or for services provided to a recipient who has exhausted annual benefits. However, billing the recipient for services not paid by Medicaid due to provider-correctable claim submission errors or untimely filing is not permissible. Medicaid recipients are exempt from co-payment requirements for maternity care and family planning services; co-pay rules do apply to well-woman gynecological office services except for recipients under age 18.

Coding, CPTs, and Billing Windows

Antepartum-only CPT CodesCPTCovered

59425	Antepartum care only; 4-6 visits
59426	Antepartum care only; 7 or more visits

Prenatal visit threshold for global billing

Global prenatal visit requirementWhen a nurse midwife provides eight (8) or more prenatal visits, performs the delivery, and provides postpartum care, the provider shall bill using an all-inclusive 'global' obstetrical code with the date of service being the date of delivery.

Visits counted in global codeVisits covered by a submitted 'global' code are not counted against the recipient's annual physician office visit limit.

Group practice billingFor 'global' obstetrical billing, services rendered by members of a group practice are considered services rendered by a single provider.

Antepartum visit count for CPT distinction

CPT 59425 definitionAntepartum care only: use CPT 59425 when billing for four to six (4–6) antepartum visits.

CPT 59426 definitionAntepartum care only: use CPT 59426 when billing for seven (7) or more antepartum visits.

Fewer than four visitsNurse midwives who provide fewer than four antepartum visits must bill using office visit procedure codes, which will count toward the recipient's annual office visit limits.

Postpartum coverage window

Postpartum coverage periodPostpartum care includes routine visits within sixty (60) days post delivery; additional claims for routine visits during this period should not be filed.

Family planning on postpartum dayFamily planning services performed by the delivering provider on the day of the postpartum exam or within five (5) days of the postpartum exam are noncovered because they are included in the postpartum exam.

Postpartum when delivery by another providerIf the midwife did not perform the delivery but provides postpartum care, family planning services within five (5) days of the postpartum exam are noncovered as they are included in the postpartum exam.

Provider Enrollment, Documentation & Billing Requirements

Billing Rule

Antepartum-only coding requirement

Use the specified antepartum-only CPT procedure codes when billing Antepartum Care Only: CPT 59425 for four to six visits and CPT 59426 for seven or more visits; if fewer than four antepartum visits are provided, bill using office visit procedure codes. Antepartum-only claims do not count against the recipient's annual physician office visit limits.

CPT 59425 — Antepartum care only; 4–6 visits
CPT 59426 — Antepartum care only; 7 or more visits
If <4 antepartum visits, use office visit procedure codes (these count toward annual office visit limits)

Note

Provider actions — none specified

No additional provider-specific actions are specified beyond those detailed elsewhere in the policy; providers should follow the enrollment, documentation, billing, and record requirements stated in this rule.

Documentation Required

Required written records for midwife files

Maintain written evidence in the midwife's file that a delivery plan in a licensed hospital existed for each patient accepted for maternity/global care, keep a written statement naming the physician(s) with whom the midwife works and the signed working arrangement, and retain a complete medical record for each recipient.

Written evidence that hospital delivery plans existed for each patient accepted for global care (filed in midwife's records).
Written statement naming physician(s) and describing the working arrangement, signed by both parties with date.
A complete medical record for each recipient.

Prior Authorization

Enrollment submission must include licensure and signed agreement

Submit a completed enrollment application with copies of current Registered Nurse and Certified Nurse Midwife licensure and the written signed agreement between the midwife and the physician consultant to the Alabama Medicaid Administrator of Nurse Midwife Program at the address provided.

Completed enrollment application
Copy of current RN licensure
Copy of current CNM licensure
Copy of the written, signed agreement between the nurse midwife and physician consultant
Send documents to the Alabama Medicaid Agency (Administrator of Nurse Midwife Program, P.O. Box 5624, Montgomery, Alabama 36103-5624)

Prior Authorization

Participation and enrollment requirements

To participate the nurse midwife must complete enrollment, be approved, sign a contract, and be issued a provider number; only in-state and out-of-state providers within a 30-mile radius of Alabama's state line who meet requirements are eligible to participate.

Complete enrollment application, be approved for enrollment, sign contract, and be issued a provider number.
Out-of-state providers are eligible only if they practice within a 30-mile radius of Alabama's state line.

Denial Risk

Hospital-employed midwife billing restriction and notification

Hospital-employed nurse midwives who are employed and paid by a hospital may not bill Medicaid for services performed for which the hospital is reimbursed; midwives with a Medicaid provider number must notify the Alabama Medicaid Agency of the name of any hospital(s) by which they are employed to prevent double payment.

If employed and paid by a hospital, the midwife may not bill Medicaid for hospital-reimbursed services.
Midwives with Medicaid provider numbers must inform the Alabama Medicaid Agency of hospital employer names regardless of regularity or frequency of employment.

Background and Scope

Nurse midwifery practice encompasses management of care for normal, healthy women and their newborns through the continuum of prenatal, intrapartum, postpartum, and well-woman gynecological services. Typical services include antepartum care and monitoring, management of labor and vaginal delivery (including routine professional hospital services related to delivery), routine postpartum visits, well-woman evaluations such as Pap screening and menopausal care, contraception counseling and procedures (except sterilization), treatment of common gynecologic problems and minor illnesses, and normal newborn care when applicable.

All nurse midwife services must be provided under appropriate physician supervision and within the scope authorized by state law. When accepting patients for maternity services, the midwife’s care plan must include arrangements for delivery to occur in a licensed hospital, and the midwife’s file should contain written evidence of those plans and a signed statement describing the working arrangement with the supervising physician. A complete medical record must be maintained for each recipient.

Nurse Midwife Program — Coverage Criteria for Certified Nurse Midwives

Sign up for all Alabama Medicaid policy alerts

Nurse Midwife Program — Coverage Criteria for Certified Nurse Midwives

Sign up for all Alabama Medicaid policy alerts

Covered Services & Criteria

Coding, CPTs, and Billing Windows

Provider Enrollment, Documentation & Billing Requirements

Background and Scope

Definitions & Legal Authority