Prenatal & Postpartum Care
Helping you improve your scores, as you improve the health of your patients.
Healthcare Effectiveness Data and Information Set (HEDIS®) scores are not only important for you as a provider; they also help guide your patients to quality care. As your trusted partner with the mutual goal of helping people lead healthier lives, Cigna is happy to provide support in every way we can. Use this quick reference guide for tips and up-to-date procedure codes that will help you maintain and even improve your HEDIS scores.
What you need to know
Prenatal care looks for the percent of patients who delivered and had prenatal care visits during the first trimester, or within 42 days of enrollment.
To count as a Prenatal visit, the following must be present:
Prenatal care visit to an OB/GYN or other prenatal care practitioner or PCP. For visits to a PCP, a diagnosis of pregnancy must be present. Documentation in the medical record must include a note indicating the date when the prenatal care visit occurred, and evidence of one of the following.
- A basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used).
- Evidence that a prenatal care procedure was performed, such as:
- Screening test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing), or
- TORCH antibody panel alone, or
- A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, or
- Echography of a pregnant uterus.
- Documentation of LMP or EDD in conjunction with either of the following.
- Prenatal risk assessment and counseling/education.
- Complete obstetrical history.
Postpartum care looks for the percent of patients who delivered and had postpartum visits within 21 to 56 days after giving birth.
To count as a postpartum care visit, the medical record must include documentation indicating the date on which a postpartum visit occurred and one of the following:
- Pelvic exam
- Evaluation of weight, blood pressure, breasts and abdomen
- Notation of "postpartum care"
HEDIS relies on diagnoses and procedure codes, as well as patient medical records, to measure performance.
Tips for improving your scores
- Schedule prenatal care visits starting in the first trimester or within 42 days of enrollment.
- Schedule your patient for a postpartum visit within 21 to 56 days from delivery.
Common billing codes accepted by HEDIS® for prenatal and postpartum care.
Delivery Codes:
| Current Procedural Terminology (CPT®) | Healthcare Common Procedure Coding System (HCPCS) | International Classification of Diseases - 10th Edition (ICD-10) |
|---|---|---|
| 59620-59622 | H1005 | O00.0 |
| 59400-59515 | 640.01-643.1 | O00.1 |
| 59610, 59618 | 644.21 | O00.2 |
| 645.11-645.21 | O00.8 | |
| 646.01-671.92 | O00.9 | |
| 672.02 | O01.0 | |
| 673.01-676.92 | O01.1 | |
| 678.01-679.12 | O01.9 | |
| V27.0-V27.6 | O02.0 | |
| O02.1 | ||
| O02.81 | ||
| O02.89 | ||
| O02.9 | ||
| O03.0 | ||
| O03.1 | ||
| O03.2 | ||
| O03.30 | ||
| O03.31 | ||
| O03.32 | ||
| O03.33 | ||
| O03.34 | ||
| O03.35 | ||
| O03.36 | ||
| O03.37 | ||
| O03.38 | ||
| O03.39 | ||
| O03.4 | ||
| O03.5 | ||
| O03.6 | ||
| O03.7 | ||
| O03.80 |
Prenatal:
| CPT | HCPCS | Revenue Code |
|---|---|---|
| 99201 - 99205 office visits | G0463 | 514 |
| 99211 - 99215 office visits | T1015 | |
| 99241 - 99245 office visits |
Ultrasounds:
| CPT |
|---|
| 76801 |
| 76805 |
| 76811-76828 |
Toxoplasma:
| CPT | Logical Observation Identifiers Names and Codes (LOINC) |
|---|---|
| 86777- 86778 | 11598-0 |
| 12261-4 | |
| 12262-2 | |
| 13286-0 | |
| 17717-0 | |
| 21570-7 | |
| 22577-1 | |
| 22580-5 | |
| 22582-1 | |
| 22584-7 | |
| 23485-6 | |
| 23486-4 | |
| 23784-2 | |
| 24242-0 | |
| 25300-5 | |
| 25542-2 | |
| 33336-9 | |
| 34422-6 | |
| 35281-5 | |
| 35282-3 | |
| 40677-7 | |
| 40678-5 | |
| 40697-5 | |
| 40785-8 | |
| 40786-6 | |
| 41123-1 | |
| 41124-9 | |
| 42949-8 | |
| 47389-2 | |
| 47390-0 | |
| 5387-6 | |
| 5388-4 | |
| 5389-2 | |
| 5390-0 | |
| 5391-8 | |
| 56990-5 | |
| 56991-3 | |
| 8039-0 | |
| 8040-8 |
Rubella Antibody:
| CPT | LOINC |
|---|---|
| 86762 | 13279-5 |
| 13280-3 | |
| 17550-5 | |
| 22496-4 | |
| 22497-2 | |
| 24116-6 | |
| 25298-1 | |
| 25420-1 | |
| 25514-1 | |
| 31616-6 | |
| 34421-8 | |
| 40667-8 | |
| 41763-4 | |
| 43810-1 | |
| 49107-6 | |
| 50694-9 | |
| 51931-4 | |
| 52986-7 | |
| 5330-6 | |
| 5331-4 | |
| 5332-2 | |
| 5333-0 | |
| 5334-8 | |
| 5335-5 | |
| 63462-6 | |
| 8013-5 | |
| 8014-3 | |
| 8015-0 |
Cytomegalovirus Antibody:
| CPT | LOINC |
|---|---|
| 86644 | 13225-8 |
| 13949-3 | |
| 15377-5 | |
| 16714-8 | |
| 16715-5 | |
| 16716-3 | |
| 22239-8 | |
| 22241-4 | |
| 22244-8 | |
| 22246-3 | |
| 22247-1 | |
| 22249-7 | |
| 24119-0 | |
| 30325-5 | |
| 32170-3 | |
| 32791-6 | |
| 32835-1 | |
| 45326-6 | |
| 47307-4 | |
| 47363-7 | |
| 47430-4 | |
| 49539-0 | |
| 5121-9 | |
| 5122-7 | |
| 5124-3 | |
| 5125-0 | |
| 5126-8 | |
| 5127-6 | |
| 52976-8 | |
| 52984-2 | |
| 59838-3 | |
| 7851-9 | |
| 7852-7 | |
| 7853-5 | |
| 784454 | |
| 9513-3 |
Herpes:
| CPT | LOINC |
|---|---|
| 86694-86696 | 10350-7 |
| 13323-1 | |
| 13324-9 | |
| 13501-2 | |
| 13505-3 | |
| 14213-3 | |
| 16944-1 | |
| 16949-0 | |
| 16950-8 | |
| 16954-0 | |
| 16955-7 | |
| 16957-3 | |
| 16958-1 | |
| 17850-9 | |
| 17851-7 | |
| 19106-4 | |
| 21326-4 | |
| 21327-2 | |
| 22339-6 | |
| 22341-2 | |
| 22343-8 | |
| 24014-3 | |
| 25435-9 | |
| 25837-6 | |
| 25839-2 | |
| 26927-4 | |
| 27948-9 | |
| 30355-2 | |
| 31411-2 | |
| 32687-6 | |
| 32688-4 | |
| 32790-8 | |
| 32831-0 | |
| 32834-4 | |
| 32846-8 | |
| 33291-6 | |
| 34152-9 | |
| 34613-0 | |
| 36921-5 | |
| 40466-5 | |
| 40728-8 | |
| 40729-6 | |
| 41149-6 | |
| 41399-7 | |
| 42337-6 | |
| 42338-4 | |
| 43028-0 | |
| 43030-6 | |
| 43031-4 | |
| 43111-4 | |
| 43180-9 | |
| 44008-1 | |
| 44480-2 | |
| 44494-3 | |
| 44507-2 | |
| 45210-2 | |
| 47230-8 | |
| 48784-3 | |
| 49848-5 | |
| 50758-2 | |
| 51915-7 | |
| 51916-5 | |
| 5202-7 | |
| 5203-5 | |
| 5204-3 | |
| 5205-0 | |
| 5206-8 | |
| 5207-6 | |
| 5208-4 | |
| 5209-2 | |
| 5210-0 | |
| 52977-6 | |
| 52981-8 | |
| 53377-8 | |
| 53560-9 | |
| 57321-2 | |
| 73559-7 | |
| 7907-9 | |
| 7908-7 | |
| 7909-5 | |
| 7910-3 | |
| 7911-1 | |
| 7912-9 | |
| 7913-7 | |
| 9422-7 |
Post-Partum
| CPT | HCPCS | International Classificaiton of Diseases – 10th Edition (ICD-10) |
|---|---|---|
| 57170 | G0101 | Z01.411 - Z01.42 |
| 58300 | Z30.430 | |
| 59430 | Z39.1 – Z39.2 | |
| 99501 | ||
| 0503F |
Pregnancy Diagnosis:
| ICD-10 |
|---|
| 80081 |
| O00.0-O04.9 |
| O07.0-O016.9 |
| O09.00-O16.9 |
| O20.0-O26.93 |
| O28.0-O36.93X9 |
| O40.1XX0-O48.1 |
| O60.00-O77.9 |
| O80, O82, O85 |
| O86.0-O92.79 |
| O98.011-O99.89 |
| O9A.111-O9A.53 |
| Z03.7-Z03.79 |
| Z33-Z33.2 |
| Z34-Z34.93 |
| Z36 |
Obstetric Panel:
| CPT |
|---|
| 80081 |
Billing and medical record documentation should always support the level of service provided at that visit.
®HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)
Reproduced with permission from HEDIS 2017, Volume 2: Technical Specifications for Health Plans by the National Committee for Quality Assurance (NCQA). HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). To purchase copies of this publication, contact NCQA Customer Support at 888-275-7585 or visit www.ncqa.org/publications.
Current Procedural Terminology (CPT) codes copyright 2016 American Medical Association. All rights reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
Uniform Bill Codes (“UB Codes”) are protected under federal copyright laws and are owned by the American Hospital Association (AHA). The UB Codes in the HEDIS specifications are included with the permission of the AHA. The UB Codes contained in the HEDIS specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting HEDIS results or using HEDIS measure results for their internal quality improvement purposes. All other uses of the UB Codes require a license from the AHA. Software vendors and all others desiring to use the UB Codes in a commercial product to generate HEDIS results, or for any other use, must obtain a commercial use license directly from the AHA. To inquire about licensing, please contact ub04@healthforum.com.