CurrentAlliance HealthPolicy 1M-2

Childbirth Education

NC Medicaid clinical coverage policy defining coverage, provider qualifications, class content and billing rules for childbirth education services for pregnant Medicaid beneficiaries, including telehealth provisions and EPSDT exceptions for beneficiaries under 21.

Policy Summary

PayerAlliance Health

PolicyChildbirth Education

Policy CodePolicy 1M-2

Change TypeTemplate update; telehealth and billing revisions

Effective DateOct 1, 2002

Next Review Date

Key ActionMaintain client records with name, DOB, Medicaid ID, dates of service, total service time, and name/title of person performing the service.

POLICY UPDATE CHANGES

Policy posted 8/15/2023 with an effective date of 4/1/2023 to reflect NC Health Choice move to Medicaid and update template language.

Added telehealth eligibility and billing rules to Attachment A (12/01/2020).

Maximum hours of instruction increased to 10 hours (8/1/08).

10 hoursComplete childbirth education series

4 hours/dayMax billable per day

10 personsMax beneficiaries per group class

S9442Primary HCPCS code listed

Coverage Summary

Childbirth education is a series of classes designed to help pregnant women and their support person understand physical and emotional changes during pregnancy, prepare for labor and delivery, and learn about postpartum care for mother and child; classes are based on goals and objectives approved by NC Medicaid and listed in the policy's class requirements.

This policy defines NC Medicaid coverage for childbirth education for pregnant Medicaid beneficiaries, permits select services to be provided via telehealth under the Telehealth policy requirements (services identified as telehealth-eligible in Attachment A), and preserves Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) exceptions for beneficiaries under 21 years of age where EPSDT criteria are met.

Medical Necessity & Coverage Criteria

General Coverage Criteria

Medicaid covers the service when medically necessary and the following ALL apply:

General Coverage Criteria - top level

Individualized and necessary: The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs
Safe and conservative alternative: The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide
Not for convenience: The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider
Beneficiary eligibility verified: Beneficiary meets eligibility requirements in Section 2.0 (e.g., enrolled in NC Medicaid and verified at time of service)

Specific Coverage - Childbirth Education Timing

Additional covered criterion:

Timing of coverage: Childbirth education is covered during pregnancy

Provider Actions & Billing Requirements

Documentation Required

Maintain client record elements

Maintain a client record that includes: client's name; date of birth; Medicaid identification number (MID); dates of service; total service time component (e.g., 1 hour = 1 unit); and the name and title of the person performing the service.

Client name
Date of birth
Medicaid identification number (MID)
Dates of service
Total service time (e.g., 1 hour = 1 unit)
Name and title of person performing the service

Billing Rule

Billing units and per-class reimbursement

Coding & Modifiers

Telehealth-eligible HCPCSHCPCSCovered

S9442

Childbirth education classes (per session)

ICD-10-CM relevant pregnancy codes (examples listed)ICD-10

O09.01
O09.02
O09.03
O09.11
O09.12
O09.13
O09.211
O09.212
O09.213
O09.291

1–10 of 44

1/5

Modifiers - TelehealthModifier

GT	Append for interactive audio-visual telehealth services (not for virtual communications or RPM)

Background & Definitions

NC Medicaid requires childbirth education classes to follow a written curriculum that outlines mandatory course objectives and the specific content covered in each class; the curriculum may be nationally recognized or newly developed but must include specified topics in pregnancy, labor and delivery, postpartum care, infant care, and other required areas.

Classes meet for 1 or 2 hours per session for a total of a complete series = 10 hours of instruction, and may include instructional materials and presentation methods appropriate to beneficiary language and literacy levels.

EPSDT: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is the federal Medicaid requirement (42 U.S.C. § 1396d(r)) that requires coverage of medically necessary services for beneficiaries under 21 to correct or ameliorate conditions identified through screening; EPSDT may override policy limits when provider documentation shows the service meets EPSDT criteria, but it does not eliminate prior approval requirements if they otherwise apply.

Revision History

2008-08-01revised

Maximum hours of instruction increased to 10 hours (complete series defined as ten hours); billing limits updated (maximum 4 hours per day, 10 hours per pregnancy).

2020-12-01revised

Telehealth eligibility and billing rules added: services marked telehealth-eligible (S9442), maximum group size for telehealth and non-telehealth group classes limited to 10, provider must inform beneficiaries of public nature of online classes, GT modifier required for interactive audio-visual telehealth claims, and telehealth claims filed with provider's usual place of service code.

2023-08-15revisedLatest

Policy Summary

PayerAlliance Health

PolicyChildbirth Education

Policy CodePolicy 1M-2

Change TypeTemplate update; telehealth and billing revisions

Effective DateOct 1, 2002

Next Review Date

Key ActionMaintain client records with name, DOB, Medicaid ID, dates of service, total service time, and name/title of person performing the service.

On This Page

Childbirth education is reimbursed per class (one- or two-hour classes). Bill only for classes the beneficiary attends and bill per date of service. The primary HCPCS code listed for this service is S9442.

Code: S9442 (Childbirth education classes)
Reimbursement: per class (1- or 2-hour session)
Bill only for classes the beneficiary attends
Bill per date of service

Billing Rule

Daily and pregnancy billing limits

Billing limits: a maximum of 4 hours of instruction may be billed per day (four 1-hour classes or two 2-hour classes) and a maximum of 10 hours of instruction may be billed per pregnancy (ten 1-hour classes or five 2-hour classes). A complete series is 10 hours.

Max per day: 4 hours
Max per pregnancy: 10 hours
Complete series: 10 hours

Billing Rule

Claim type and coding specificity

Professional claims should be submitted using CMS-1500/837P. Report the most specific CPT, HCPCS and ICD-10-CM codes to the highest level of specificity that supports medical necessity.

Claim type: Professional (CMS-1500/837P)
Report most specific CPT/HCPCS codes that accurately describe the service
Report ICD-10-CM codes to highest specificity supporting medical necessity

Billing Rule

Telehealth billing requirements

Telehealth-eligible childbirth education (HCPCS S9442) may be provided via interactive audio-visual telehealth. For telehealth claims append modifier GT to the CPT/HCPCS code. Telehealth claims should be filed with the provider's usual place of service code(s). Services delivered via telehealth must meet the interactive audio-visual requirement.

Telehealth code: S9442
Modifier: GT required for interactive audio-visual telehealth
Place of service: file telehealth claims with provider's usual place of service code(s)
Requirement: interactive audio-visual communication (GT not for virtual communications or RPM)

Documentation Required

Verify Medicaid eligibility at each service

Verify each beneficiary's NC Medicaid eligibility at each time a service is rendered. Eligibility may affect service availability or restrictions.

Prior Authorization

Prior approval not required

Prior approval is not required for Medicaid beneficiaries for childbirth education. However, if the service otherwise requires prior approval, that requirement still applies; EPSDT does not eliminate prior approval requirements for services that require it.

Documentation Required

Provider qualification verification

Provider agencies must verify and retain documentation of staff qualifications and certifications for childbirth educators. Educators must have certification from a nationally recognized organization or meet State-approved childbirth education program requirements; a copy of verification must be maintained by the provider agency.

Verify and retain staff qualification documentation
Acceptable qualifications: national childbirth educator certification (e.g., ICEA, Lamaze) or State-approved program

Policy posted 8/15/2023 with an effective date of 04/01/2023 to reflect NC Health Choice move to Medicaid and updated template language; section revisions applied to all sections and attachments.