Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 1 - PHYSICIANS › Section 317:30-5-22 - Obstetrical care

Current through Vol. 41, No. 20, July 1, 2024
(a) Obstetrical
				  (OB) care is billed using the appropriate CPT codes for maternity care and
				  delivery. The date of delivery is used as the date of service for charges for
				  total OB care. Inclusive dates of care should be indicated on the claim form as
				  part of the description. Payment for total OB care includes all routine care,
				  and any ultrasounds performed by the attending physician provided during the
				  maternity cycle unless otherwise specified in this Section. For payment of
				  total OB care, a physician must have provided care for more than one (1)
				  trimester. To bill for prenatal care only, the claim is filed after the member
				  leaves the provider's care. Payment for routine or minor medical problems will
				  not be made separately to the OB physician outside of the antepartum visits.
				  The antepartum care during the prenatal care period includes all care by the OB
				  attending physician except major illness distinctly unrelated to the
				  pregnancy.
(b) Procedures paid
				  separately from total OB care are listed in (1) - (8) of this subsection.
(1) The completion of an American College of
				  Obstetricians and Gynecologist (ACOG) assessment form or form covering same
				  elements as ACOG, and the most recent version of the Oklahoma Health Care
				  Authority's (OHCA) Prenatal Psychosocial Assessment are reimbursable when both
				  documents are included in the prenatal record. SoonerCare allows one (1)
				  assessment per provider and no more than two (2) per pregnancy.
(2) Medically necessary real time antepartum
				  diagnostic ultrasounds will be paid in addition to antepartum care, delivery,
				  and postpartum OB care under defined circumstances. To be eligible for payment,
				  all ultrasound reports must meet the guideline standards published by the
				  American Institute of Ultrasound Medicine (AIUM).
(A) One (1) ultrasound will be covered in the
				  first trimester of an uncomplicated pregnancy. Both an abdominal and vaginal
				  ultrasound may be allowed when clinically appropriate and medically necessary.
				  The ultrasound must be performed by a board eligible/board certified
				  obstetrician-gynecologist (OB-GYN), radiologist, or a board eligible/board
				  certified maternal-fetal medicine specialist. In addition, this ultrasound may
				  be performed by a certified nurse midwife (CNM), family practice physician or
				  advanced practice nurse practitioner (APRN) in obstetrics with a certification
				  in OB ultrasonography.
(B) One (1)
				  ultrasound after the first trimester will be covered. This ultrasound must be
				  performed by a board eligible/board certified OB-GYN, radiologist, or a board
				  eligible/board certified maternal-fetal medicine specialist. In addition, this
				  ultrasound may be performed by a CNM, family practice physician, or APRN with
				  certification in OB ultrasonography.
(C) One (1) additional detailed ultrasound is
				  allowed by a board eligible/board certified maternal fetal specialist or
				  general obstetrician with documented specialty training in performing detailed
				  ultrasounds. This additional ultrasound is allowed to identify or confirm a
				  suspected fetal/maternal anomaly. This additional ultrasound does not require
				  prior authorization. Any subsequent ultrasounds will require prior
				  authorization.
(3)
				  Standby attendance at cesarean section (C-section), for the purpose of
				  attending the baby, is compensable when billed by a physician or qualified
				  health care provider not participating in the delivery.
(4) Anesthesia administered by the attending
				  physician is a compensable service and may be billed separately from the
				  delivery.
(5) Amniocentesis is not
				  included in routine OB care and is billed separately. Payment may be made for
				  an evaluation and management service and a medically indicated amniocentesis on
				  the same date of service. This is an exception to general information regarding
				  surgery found at Oklahoma Administrative Code (OAC)
				  317:30-5-8.
(6) Additional payment is not made for the
				  delivery of multiple gestations. If one (1) fetus is delivered vaginally and
				  additional fetus(es) are delivered by C-section by the same physician, the
				  higher-level procedure is paid. If one (1) fetus is delivered vaginally and
				  additional fetus(es) are delivered by C-section, by different physicians, each
				  should bill the appropriate procedure codes without a modifier. Payment is not
				  made to the same physician for both standby and assistant at
				  C-section.
(7) Reimbursement is
				  allowed for nutritional counseling in a group setting for members with
				  gestational diabetes. Refer to OAC
				  317:30-5-1076(5).
(8) Limited OB ultrasounds are covered in an
				  emergency room (ER) setting when medically necessary.