ModifiedAlliance HealthPolicy 1E-5

Obstetrical Services

Defines coverage, eligibility, and billing for antepartum care, labor and delivery, and postpartum services for NC Medicaid beneficiaries; applies to providers billing Medicaid and affected beneficiaries in North Carolina.

Policy Summary

PayerAlliance Health

PolicyObstetrical Services

Policy CodePolicy 1E-5

Change TypeMaterial and technical revisions (telehealth, postpartum extension, billing)

Effective DateAmended June 15, 2024

Next Review Date

Key ActionVerify Medicaid eligibility at each visit and document required information to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

Added Section 'Hybrid Telehealth Visit with Supporting Home Visit' for coverage.

Changed MPW postpartum coverage end from last day of month with 60th postpartum day to last day of month in which 12-month postpartum period ends (legislated postpartum extension).

Added GT modifier criteria for telehealth claims for global/package billing and individual visit billing.

Added billing guidance for Multiple Births including required ICD-10-CM multiple gestation diagnosis codes and additional units to be billed.

Added guidance permitting initial antepartum visit and pregnancy risk screen via telehealth but requiring an in-person follow-up within the first trimester if initial visit was telehealth.

Updated definitions and sections to remove gendered language and replace terms (e.g., 'female' to 'beneficiary' or 'individual').

Added United States Preventive Services Task Force (USPSTF) Recommendations.

Jun 15, 2024Amended date

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

Eligibility-based Coverage

Covered when beneficiary meets the eligibility category conditions:

Regular Medicaid: Beneficiaries enrolled in Regular Medicaid are eligible for antepartum, labor and delivery, and postpartum care and have full Medicaid coverage through at least the last day of the month in which the 12-month postpartum period ends.

Medicaid for Pregnant Women (MPW): Beneficiaries with MPW coverage are eligible for antepartum, labor and delivery, and postpartum care in addition to full Medicaid coverage; MPW eligibility ends on the last day of the month in which the 12-month postpartum period ends (NCGA SL 2021-180).

Population Groups Without State Coverage: For population groups without state coverage, Medicaid covers emergency services for treatment of an emergency condition for actual dates services are provided up to a maximum of five calendar days; the local department of social services determines labor and delivery emergency coverage dates.maximum 5 calendar days for emergency services

NC Medicaid determines coverage eligibility for other pregnancy-related emergencies.

Special Eligibility Provisions

Coverage under special eligibility provisions:

Presumptive Eligibility: Pregnant beneficiaries determined presumptively eligible by a qualified provider may receive ambulatory antepartum care while formal Medicaid eligibility is pending; presumptive eligibility is based on evidence of pregnancy and income only and is limited to one presumptive eligibility period per pregnancy. The beneficiary must apply for Medicaid no later than the last day of the month following the month of presumptive determination to remain eligible.application by last day of month following presumptive determination

If the beneficiary fails to apply within the time frame, presumptive eligibility ends as described.

Retroactive Eligibility: Retroactive eligibility applies to this policy.

General Criteria Covered

Covered when ALL of the following are met

General medical necessity: The procedure, product, or service is individualized, specific, and consistent with symptoms or a confirmed diagnosis and is not in excess of the beneficiary's needs.

Safety and conservatism: The procedure, product, or service can be safely furnished and there is no equally effective and more conservative or less costly treatment available statewide.

Not primarily for convenience: The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, caregiver, or provider.

Antepartum Care and Package Criteria

Antepartum care covered when criteria below are met

Routine antepartum visits: Monthly visits up to 28 weeks; biweekly visits 28-36 weeks; weekly visits from 36 weeks until delivery. Routine antepartum visits include recording weight, blood pressure, fetal heart tones and, when indicated, chemical urinalysis.frequency as stated

Routine uncomplicated pregnancy

Non-routine individual antepartum services: Individual evaluation and management (E/M) codes are covered when: (a) a routine, uncomplicated pregnancy requires more than the current ACOG recommended number of visits; (b) all prenatal visits occur after a high-risk diagnosis; or (c) less than four antepartum care visits are rendered before delivery or termination of provider-patient relationship.

Local Health Departments should bill appropriate E/M codes for high-risk antepartum care.

Antepartum package services are covered when the attending provider rendering the antepartum care does not perform the delivery and the attending provider or group has rendered at least four antepartum care visits to the pregnant beneficiary before delivery.

EPSDT Exception Criteria

EPSDT Exception

EPSDT coverage for under-21: For beneficiaries under 21, EPSDT requires coverage of services, products, or procedures that are medically necessary to correct or ameliorate a condition identified through screening, even if such services exceed standard policy limits, provided they are safe and effective.

42 U.S.C. §1396d(r)

Prior approval still required: If a service ordinarily requires prior approval, EPSDT status does not eliminate the prior approval requirement; providers must follow NCTracks and EPSDT guidance for prior approval processes.

Section 2.2.1.b

Antepartum Care Package

Antepartum Care Package Services

Antepartum Package: Medicaid covers antepartum package services when the attending provider rendering the antepartum care does not perform the delivery and the attending provider or group rendered at least four antepartum care visits to the pregnant beneficiary before delivery.>=4 visits

Subsection 3.3.1

Global Obstetrics Package

Global Obstetrics Package Services

Global/package coverage: Antepartum care, labor and delivery, and postpartum care are covered as an all-inclusive service when at least four antepartum visits were rendered before delivery and the same provider who rendered the antepartum care performs the delivery and postpartum care.>=4 visits

E/M services in excess of three additional visits require supporting documentation.

Postpartum Care

Postpartum Care Package Services

Postpartum package coverage: Postpartum package services are covered when the attending provider performed the delivery and provided the postpartum care, or when the provider performed postpartum care only.postpartum period defined to month containing 60th day

Telehealth prenatal/postpartum visits (interactive audio and video) count as visits; telephone/online communications do not.

Postpartum visit components: Postpartum care must include an interaction within the first 3 weeks of delivery and a comprehensive postpartum examination with contraceptive counseling by the end of the defined postpartum period; contraceptive counseling is part of the postpartum visit and not separately reimbursable. For Pregnancy Management Program billing, S0281 must be billed within 60 days of delivery.interaction within 3 weeks

Subsection 3.6 and related PMP guidance.

Labor and Delivery

Labor and Delivery Services

Delivery types: Medicaid covers vaginal delivery (with or without episiotomy), assisted vaginal delivery (forceps or vacuum), and cesarean delivery when determined to be the safer method for the pregnant beneficiary and the baby.

Elective cesarean without indication should not be performed before 39 weeks and beneficiaries should be counseled about risks.

Depression Screening

Postpartum Depression Screening

Depression screening: Obstetric, family practice, and pediatric providers may be reimbursed for up to four brief emotional/behavioral assessments with scoring and documentation using a standardized instrument during the first year after delivery (or until beneficiary eligibility ends) in addition to global obstetrics and postpartum package services; if a problem is identified, refer for treatment.<=4 assessments in first year

MPW eligibility ends last day of month in which 12-month post-pregnancy period ends.

Stand-by Anesthesia

Stand-by Services

Stand-by anesthesia coverage: Anesthesia physician or CRNA stand-by service is covered for high-risk deliveries when requested by a physician and a diagnosis substantiating high risk is documented on the claim; only stand-by services related to the pregnant beneficiary may be billed. Health records documenting the high-risk delivery and need for stand-by services must be available upon request.documented high-risk diagnosis on claim

Attendance at delivery and initial stabilization of the newborn during a high-risk delivery is included.

Telehealth and Hybrid Visits

Telehealth / Hybrid Care

Telehealth visits count: Prenatal and postpartum visits conducted via interactive audio and video telehealth count as visits within global/package services; telephone or online virtual patient communications do not count.telehealth must be interactive audio/video

Hybrid telehealth with home visit: A hybrid model (telehealth visit with a supporting home visit by an appropriately trained delegated staff person) is allowed when medically necessary; delegated staff may perform vaccinations in the home if within scope and applicable requirements are met. Reimbursement for this model is open to new and established patients.

Delegated staff may conduct tests or screenings and administer vaccines when appropriate.

Limitations

Coverage limitations apply as follows:

Antepartum package: Labor antepartum care package services are covered once per pregnancy; in special circumstances (e.g., beneficiary moves), up to three different providers may bill for antepartum care 4-6 visits (does not apply to different providers in the same group).one package per pregnancy; up to 3 providers in special circumstances

Postpartum coverage extension: Postpartum health care coverage extends through the end of the month in which the 12-month post-pregnancy period ends.12 months

Reflects legislated MPW postpartum extension.

Stand-by services limit: Stand-by services related to a pregnant beneficiary for a high-risk delivery are limited to two hours per day.2 hours/day

Telehealth originating site facility fee (hybrid home visit)

Eligible providers may bill telehealth originating site facility fee for hybrid visits when all conditions are met:

Delegated staff requirement: Assistance in the home must be delivered by an appropriately trained delegated staff person.

Date of service: The originating site facility fee must be billed with the date of service for which the home visit is conducted.

Modifiers and place of service: The telehealth originating site facility fee must be appended with the GT modifier and billed with place of service '12' to designate the home as the originating site.

Global/package inclusion: The antepartum or postpartum hybrid telehealth visit is included in the global or package code and no separate E/M code is billed outside the package for the provider's portion of the home visit.

GT modifier rules

Telehealth claims must follow these modifier rules:

GT modifier use for global/package: Append the GT modifier to the global or package code to indicate that one or more visits were conducted via telehealth under that package; this modifier is not appropriate for virtual patient communications or remote patient monitoring.

GT modifier use for individual visits: When OB services are provided and billed per visit, append the GT modifier to each individual visit conducted via telehealth; GT is not appropriate for virtual patient communications or remote patient monitoring.

Initial antepartum visit telehealth

Initial antepartum visit and pregnancy risk screening:

Initial visit telehealth option: The initial antepartum visit and pregnancy risk screen may be conducted via telehealth or in-person; to promote early initiation of prenatal care, providers shall conduct the initial visit via telehealth or in-person in the office or clinic setting.

In-person follow-up after telehealth initial visit: If the initial visit is conducted via telehealth, a follow-up in-person visit must occur within the first trimester of pregnancy.follow-up in person within first trimester

Applies to eligible providers conducting antepartum care via telehealth.

Telehealth prenatal/postpartum coverage

Covered when ALL of the following are met

Eligible provider: Visit is conducted by an eligible provider (physician, nurse practitioner, physician assistant, or certified nurse midwife).

Visit type: Antepartum and postpartum care visits may be conducted via telehealth (interactive audio and video) and not via virtual patient communications such as telephone conversations.

Telehealth visits count toward global/package services; telephone/online communications do not.

Initial visit requirement: Initial antepartum visit and pregnancy risk screen must be conducted via telehealth or in-person; if the initial visit is telehealth, a follow-up visit must be in person within the first trimester.

Originating site facility fee criteria

Reimbursement for originating site facility fee allowed when ALL of the following are met

Delegated staff present: Assistance delivered in the home must be provided by an appropriately trained delegated staff person.

Date of service billed: The originating site facility fee must be billed with the date of service for which the home visit is conducted.

Modifiers/Place of Service: The originating site facility fee must be appended with the GT modifier and billed with place of service '12' to designate the home.

Individual prenatal visit billing

Covered when ALL of the following are met

Home Service E/M billing: Providers billing individual prenatal visits shall bill the appropriate level Home Service evaluation and management code for each telehealth visit with a supporting home visit by an appropriately trained delegated staff person.

Originating site fee exclusion: Providers billing individual prenatal visits should not bill the originating site facility fee.

Tobacco cessation counseling coverage

Covered when ALL of the following are met

CPT code: Tobacco cessation counseling must be billed with CPT code 99406 or 99407.

Diagnosis code: An appropriate tobacco use disorder diagnosis code must be included on the claim.

Telehealth modifier: Append modifier GT if the counseling is performed via telehealth.

Coverage is not reimbursed for counseling in the home setting by any provider and counseling cannot be billed in addition to certain other home services as specified elsewhere.

The policy contains dedicated sections titled "When the Procedure, Product, or Service Is Not Covered" that list both general and specific exclusions. These sections are referenced in the table of contents and provide the formal location where non‑covered items and circumstances are described in full detail; providers should consult those sections in the full policy for specific billing and coverage determinations.

Presumptive eligibility for pregnant beneficiaries is allowed when a qualified provider determines eligibility based on evidence of pregnancy and income, but presumptive eligibility is limited to one presumptive eligibility period per pregnancy. The beneficiary must apply for Medicaid by the last day of the month following the month of presumptive determination to remain eligible.

General exclusions include situations where the beneficiary does not meet the policy eligibility requirements or the coverage criteria in Section 3.0, duplication of another provider's services, and services that are experimental, investigational, or part of a clinical trial. Specific not‑covered items called out in the policy include duplicative obstetrical services, home pregnancy tests, keepsake ultrasounds or ultrasounds performed solely for fetal gender determination, paternity testing, parenting classes, home tocolytic infusion therapy, and more than three pregnancy risk screenings per pregnancy.

Non‑emergency services are not covered for population groups without state coverage; only emergency services (including emergency labor and delivery when applicable) are covered for these individuals. The policy explicitly notes that sterilization procedures are not considered emergency services and therefore are not covered for individuals without state coverage. Certain procedures (for example, care for an ectopic pregnancy) are only covered when performed as emergency care.

Stand‑by services have defined exclusions: stand‑by services are not covered for pre‑anesthesia evaluations, and the policy prohibits billing stand‑by services when the same provider is providing stand‑by for both the beneficiary and the newborn. Stand‑by anesthesia coverage when allowed requires a documented high‑risk diagnosis on the claim and applies only to services related to the pregnant beneficiary.

Obstetric services for Medicaid for Pregnant Women (MPW) beneficiaries do not require prior approval per the policy. However, prior approval may be required for certain non‑obstetric services and providers should consult the referenced clinical coverage policies and NCTracks guidance for prior approval requirements for non‑obstetric care.

The policy states that attendance at delivery may not be billed together with newborn resuscitation. Providers should follow the coding and billing guidance in the policy and applicable manuals to avoid submitting conflicting or duplicative delivery and newborn procedure charges.

Tobacco cessation counseling delivered in the home setting is not reimbursed by Medicaid; providers must bill tobacco cessation services only when delivered in settings and under conditions allowed by the policy and using the required CPT codes and diagnosis codes.

Tobacco cessation counseling billed with CPT codes 99406 or 99407 cannot be billed in addition to certain visits: it is not payable on the same day as a postnatal home assessment, skilled nurse visit, newborn home visit, OB Care Manager (OBCM) visit, or Care Management for At‑Risk Children (CMARC) visit. When provided via telehealth, the GT modifier must be appended as required.

This policy contains a complete set of Not‑Covered sections elsewhere in the full document. The table of contents and later sections identify where general and specific criteria that render a service non‑covered are listed; consult those sections in the full policy for comprehensive exclusion details.

Services that are unsafe, ineffective, experimental or investigational, or not medical in nature are not required to be provided under EPSDT and are therefore treated as not medically necessary. The policy reiterates that such services are not mandated for coverage under the EPSDT provisions.

Ultrasound studies performed solely to determine fetal gender or to produce keepsake pictures are specifically listed as not covered. Similarly, home pregnancy tests are not covered. These items are identified as not medically necessary when performed for non‑medical or convenience purposes.

No additional content required for this placeholder block in the available excerpt; providers should refer to the full policy for any subject matter not detailed in these extracts.

Billing Codes, Modifiers, and Coding Rules

Attachment A: Claims-Related Information (codes and billing guidance referenced)mixed

No codes listed

Required CPT for initial prenatal visitCPTCovered

0500F

Initial prenatal care visit

Covered CPT/HCPCS Codes referencedCPT|HCPCSCovered

0503F	Postpartum care (report at comprehensive postpartum visit in addition to appropriate visit coding)
S0281	Pregnancy Management Program billing; must be billed within 60 days of delivery

Delivery CPT codes (referenced)mixedCovered

59400	Vaginal delivery per CPT listing
59409	Vaginal delivery of twins/with modifiers
59410	Vaginal delivery (other CPT listed)
59425	Post-delivery services (CPT listed)
59426	Post-delivery services (CPT listed)
59430	Obstetrical care (CPT listed)
59510	Cesarean delivery
59514	Cesarean delivery (other)
59515	Cesarean delivery (other)
59610	VBAC delivery (CPT listed)

1–10 of 16

1/2

Claims modifiers for multiple gestationmixed

Modifier 51	Appropriate modifier used with multiple delivery CPTs as indicated (e.g., 59409 Modifier 51)
Multiple gestation diagnosis codes	Appropriate ICD-10-CM multiple gestation diagnosis codes must be used (see multiple gestation code group)

Multiple birth delivery pairings (examples)mixed

59400 / 59409 / 59510 / 59618 / 59610 / 59612

Delivery CPT pairings and modifier guidance for multiple birth scenarios as referenced in policy text

Multiple gestation ICD-10-CM codesICD-10Covered

O30.001	Twin, ICD-10-CM
O30.002	Twin, ICD-10-CM
O30.003	Twin, ICD-10-CM
O30.011	Twin, ICD-10-CM
O30.012	Twin, ICD-10-CM
O30.013	Twin, ICD-10-CM
O30.031	Twin, ICD-10-CM
O30.033	Twin, ICD-10-CM
O30.041	Twin, ICD-10-CM
O30.042	Twin, ICD-10-CM

1–10 of 27

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Delivery and PMP related CPT/HCPCS codesmixedCovered

59400	Vaginal delivery per CPT listing
59409	Vaginal delivery of twins/with modifiers
59410	Vaginal delivery (other CPT listed)
59425	Post-delivery services
59426	Post-delivery services
59430	Obstetrical care
59510	Cesarean delivery
59514	Cesarean delivery (other)
59515	Cesarean delivery (other)
59610	VBAC delivery (CPT listed)

1–10 of 17

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FQHC/RHC specific billing codesCPT | HCPCSCovered

T1015	Core obstetrics billing for postpartum screenings in FQHCs
96161	Postpartum depression screening (billed with EP modifier) in Well Child visits

Tobacco cessation CPT codesCPTCovered

99406	Tobacco cessation counseling, intermediate
99407	Tobacco cessation counseling, intensive

Modifiers/Place of ServiceModifier

GT	Modifier indicating telehealth (used for originating site facility fee and tobacco counseling via telehealth)
Place of Service 12	Designates originating site was the home

Home Service E/M codesCPTCovered

Home service E/M codes

Appropriate level Home Service evaluation and management codes to be billed for each telehealth visit with a supporting home visit

Home Service E/M codesCPTCovered

Home service E/M codes

Appropriate level Home Service evaluation and management codes to be billed for each telehealth visit with a supporting home visit

Postpartum coverage period — MPW and Regular Medicaid

Postpartum coverage period (MPW & Regular Medicaid)Coverage extends through at least the last day of the month in which the 12-month postpartum period ends.

Postpartum package period (Medicaid definition)The standard postpartum period (for postpartum package components) is defined separately as delivery through the end of the month containing the 60th postpartum day.

Referral for continued coverage after 12 monthsFor continued Medicaid services beyond the 12-month post-pregnancy period, refer MPW beneficiaries to the Department of Social Services for eligibility determination.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior approval for MPW Beneficiaries

Prior approval is not required for Obstetric Services for MPW beneficiaries; however, prior approval may still be required for non-obstetric services per applicable clinical coverage policies.

Medicaid shall not require prior approval for Obstetric Services for MPW beneficiaries.
Refer to NC Medicaid clinical coverage policies for prior approval requirements for non-obstetric services: https://medicaid.ncdhhs.gov/providers/program-specific-clinical-coverage-policies

Prior Authorization

Prior approval requirement for under-21 (EPSDT)

If a service requires prior approval, beneficiaries under 21 years of age (EPSDT) still require prior approval; providers must follow NCTracks guidance and EPSDT provider resources for additional information.

Prior approval requirement remains in effect for beneficiaries under 21 even under EPSDT.
See NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for details: https://www.nctracks.nc.gov and https://medicaid.ncdhhs.gov/

Policy Background and Scope

This policy addresses comprehensive obstetrical services including antepartum care, labor and delivery, and postpartum care. It aligns with standards and references from national specialty bodies and resources used in perinatal care guidance. Providers should follow the policy when delivering obstetrical services and consult referenced professional guidance for clinical standards of care.

Key Definitions

High risk pregnancy — definition and examples

DefinitionHigh risk pregnancy: a pregnancy that threatens the health or life of the pregnant beneficiary or the fetus and often requires specialized care.

Common risk factorsRisk factors include existing health conditions, overweight/obesity, multiple births, and extremes of maternal age.

Implication for servicesHigh-risk designation may justify stand-by anesthesia services and additional monitoring or specialty care as documented and billed appropriately.

Ambulatory Antepartum Care — definition

DefinitionAmbulatory Antepartum Care: medically necessary pregnancy-related health care services provided on an outpatient basis.

Typical components

Policy Revisions and Material Changes

2024-06-15policy_revisionLatest

Clarified postpartum package billing and distinguished 12-month MPW postpartum coverage (legislated postpartum extension); removed ACOG recommendations for postpartum period and limited S0281 billing after 60 days post-delivery; added billing guidance for multiple births in Attachment A.

2024-04-01policy_revision

Added Modifier GT criteria for telehealth claims (global/package and individual visit billing); updated telehealth and place-of-service billing guidance and revised Attachment A and related billing tables.

2022-04-01policy_revision

Policy Summary

PayerAlliance Health

PolicyObstetrical Services

Policy CodePolicy 1E-5

Change TypeMaterial and technical revisions (telehealth, postpartum extension, billing)

Effective DateAmended June 15, 2024

Next Review Date

Key ActionVerify Medicaid eligibility at each visit and document required information to avoid claim denials.

SourceLink

On This Page

Note

Refer to NCTracks and Medicaid guidance

Providers must comply with NCTracks billing guidance, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies for coverage, reimbursement, and prior authorization instructions.

Follow the NCTracks Provider Claims and Billing Assistance Guide for submitting claims and prior approval processes.
Refer to Medicaid bulletins, fee schedules, and clinical coverage policies for specific reimbursement and prior approval details.

Denial Risk

Non-emergency services are not covered for population groups without state coverage

Non-emergency antepartum and postpartum services are not covered for individuals who are only eligible for emergency services (no state coverage). Sterilization is not an emergency service and is not covered for undocumented aliens.

Non-emergency services are not covered for individuals without state coverage who are only eligible for emergency services.
Sterilization procedures are not covered for undocumented aliens.

Billing Rule

Stand-by services are not covered in certain situations

Stand-by services have billing limits: only stand-by services related to the pregnant beneficiary for high-risk deliveries may be billed; stand-by services for pre-anesthesia evaluations are not covered; and stand-by services billed for both the beneficiary and newborn by the same provider are not covered.

Stand-by anesthesia services covered only for physician stand-by at high-risk deliveries and must be requested by a physician with a documented high-risk diagnosis.
Stand-by services for pre-anesthesia evaluations are not covered.
Stand-by services for both the beneficiary and the newborn when provided by the same provider are not covered.

Billing Rule

Home originating site fee requirements

To be reimbursed for telehealth-originating site facility fees with supporting home visits, providers must meet all requirements for each visit: a trained delegated staff person must provide the home assistance; bill the fee with the date of service for the home visit; append GT modifier and place of service 12; and note that the hybrid telehealth/home visit is included in the global/package code.

Delegated staff delivering home assistance must be appropriately trained.
Originating site facility fee billed with date of service of the home visit, GT modifier, and POS 12.
Hybrid telehealth/home visit is included in the global or package obstetric code — do not bill a separate E/M for the provider portion.

Billing Rule

Tobacco cessation billing requirements

Tobacco cessation counseling must be billed with CPT 99406 or 99407 plus an appropriate tobacco use disorder diagnosis code; append modifier GT if delivered via telehealth. Counseling provided in the home setting is not reimbursed. Do not bill tobacco cessation in addition to certain other postpartum/home services as listed.

Use CPT codes 99406 or 99407 with a tobacco use disorder diagnosis code.
Append GT modifier if counseling provided via telehealth.
Coverage is not reimbursed for tobacco cessation counseling delivered in the home setting.
Tobacco cessation counseling cannot be billed in addition to a postnatal home assessment, skilled nurse visit, newborn home visit, OB Care Manager visit (OBCM), or CMARC visit.

Documentation Required

Presumptive eligibility documentation

Documentation for presumptive eligibility must include evidence of pregnancy and income; the beneficiary must apply for Medicaid by the last day of the month following the month they are determined presumptively eligible to remain eligible through the determination period.

Presumptive eligibility is based on evidence of pregnancy and income only.
Beneficiary must apply for Medicaid no later than the last day of the month following the month of presumptive eligibility to retain coverage during application review.
Only one presumptive eligibility period is allowed per pregnancy.

Documentation Required

Pregnancy risk screening form

Providers must use the Pregnancy Risk Screening Form at the initial prenatal encounter, complete it as indicated, refer beneficiaries for pregnancy care management if risk factors are identified, and provide a copy to the high-risk case management agency.

Complete the pregnancy risk screening form during the initial prenatal visit.
Provide a copy of the form to the high-risk case management agency when indicated.
Refer beneficiaries with identified risk factors for pregnancy care management assessment.

Documentation Required

Coding specificity and multiple birth documentation

Report diagnosis and procedure codes to the highest level of specificity that supports medical necessity. For multiple births follow the policy billing rules and submit operative notes as required when more than four infants are involved.

Use current ICD-10-CM and PCS editions and code to highest specificity supporting medical necessity.
Follow 'Billing for Multiple Births' requirements; for more than four infants submit the first claim electronically and provide operative notes as requested for subsequent claims.

Documentation Required

Home visit documentation

Home visit documentation must support that an appropriately trained delegated staff person was present, include the date of service, and meet all billing requirements (modifiers, POS) for originating site fees when applicable.

Document presence and training status of delegated staff for home visits.
Document the date of service and link to the associated telehealth visit when billing originating site fees.
Ensure required modifiers and place of service codes are used (GT and POS 12) to qualify for originating site facility fee reimbursement.

EPSDT — definition and implications

DefinitionEPSDT (Early and Periodic Screening, Diagnostic, and Treatment): a federal Medicaid requirement (42 U.S.C. §1396d(r)) obligating coverage for medically necessary services for beneficiaries under 21 to correct or ameliorate health problems identified through screening.

ScopeEPSDT may require coverage beyond standard policy limits if services are medically necessary and safe and effective for the beneficiary under 21.

Prior approval noteIf a service ordinarily requires prior approval, EPSDT beneficiaries under 21 still must follow prior approval procedures where applicable.

Postpartum period — standard definition and relation to MPW

DefinitionPostpartum period (standard Medicaid package): period between delivery and the end of the month in which the 60th postpartum day falls.

Separation from 12-month MPW extensionThis standard postpartum period is distinct from the 12-month MPW postpartum extension, which extends coverage through the last day of the month containing 12 months post-pregnancy.

Postpartum package componentsIncludes management immediately after delivery, interaction within first 3 weeks, and comprehensive postpartum exam with contraceptive counseling by end of the defined postpartum period.

Stand-by anesthesia services — definition and billing conditions

DefinitionStand-by anesthesia services: anesthesia physician or CRNA stand-by service available for high-risk deliveries; service must be requested by a physician and a diagnosis substantiating high risk must be documented on the claim.

Billing limitsOnly stand-by services related to the pregnant beneficiary can be billed; attendance at delivery and initial newborn stabilization during high-risk delivery are covered.

DocumentationHealth records documenting high-risk delivery need not accompany the claim but must be available on request by NC Medicaid or DHHS fiscal contractor.

Postpartum period clarification — standard vs 12-month extension

ClarificationThe standard postpartum period (through the month containing day 60) is separate from the MPW 12-month postpartum coverage extension; both definitions are used in the policy for different purposes.

Postpartum package timingPostpartum package services reference the 60-day postpartum period for package components and coding (e.g., CPT 0503F).

MPW extension effectMPW and Regular Medicaid eligibility periods are extended to the last day of the month in which the 12-month postpartum period ends for coverage eligibility purposes.

Eligible providers for telehealth antepartum/postpartum visits

Eligible providers for telehealth antepartum/postpartum visitsPhysicians, nurse practitioners, physician assistants, and certified nurse midwives may conduct antepartum and postpartum care visits via telehealth (interactive audio and video).

Telehealth modality restrictionVisits may not be conducted via virtual patient communication (e.g., telephone); telehealth must be interactive audio/video.

Initial visit requirementInitial antepartum visit and pregnancy risk screen may be telehealth or in-person; if initial visit is telehealth, an in-person follow-up is required within the first trimester.

Telehealth originating site facility fee — definition and billing conditions

DefinitionTelehealth originating site facility fee: fee billed to reflect additional cost of a delegated staff person attending the patient's home for a hybrid telehealth/home visit.

Billing conditionsTo be reimbursed, the home assistance must be delivered by an appropriately trained delegated staff person; the fee must be billed with the date of service for the home visit; append GT modifier and bill Place of Service '12' to designate home.

Global/package inclusionWhen billing global/package codes the hybrid telehealth visit is included in the package and no separate E/M code may be billed for the provider's portion of the home visit.