Coverage Policy 1E-5, Obstetrical Services has been revised with an effective date of April 1, 2024. Revisions are applicable to both NC Medicaid Managed Care and NC Medicaid Direct.

Updates include the following:

  • LMP is to be recorded in Field 14 on the CMS-1500 (Professional Claim)
  • CPT code 0500F (Initial Prenatal Care visit) is to be documented for the date of service when a pregnant beneficiary is seen and evaluated by an OB provider which includes an Obstetrician (OB), Certified Nurse Midwife, Nurse Practitioner or Physician’s Assistant This code is not to be used for any pregnancy confirmation visit prior to the initial assessment by the OB provider.
  • If a practice or health department assumes care during a pregnancy, the initial visit with the OB provider will also be recorded with 0500F.
  • CPT code 0503F (Postpartum Care Visit) is to be documented on claim line 1 at the postpartum visit. This applies to new and existing practice beneficiaries. If postpartum care is included in a global or package service, a claim may be submitted with only 0503F on claim line 1. The date of service will be the date of the first postpartum visit.
  • Providers will have until July 1, 2025, to follow billing both 0500F and 0503F. After this date, claims for delivery will deny if 0500F is not in history in NCTracks. Global package claims will require 0500F on line 1 and delivery code on line 2 if not already submitted.
  • Added group prenatal care, effective July 1, 2023, as an optional service that may be provided to pregnant beneficiaries. Medicaid shall pay an incentive for group prenatal care when five or more visits are attended and documented in the health record. Records of this attendance must be available to NC Medicaid Direct or the NC Medicaid Managed Care health plans upon request. For the incentive, providers will bill CPT code 99078 with modifier TH.
  • Increased the allotted number of brief emotional assessments to four to align with Health Check guidelines.

Providers are encouraged to review Clinical Coverage Policy 1E-5, Obstetrical Services for a detailed overview of other general language and formatting updates to the policy. Additionally, providers can also see the Maternity Coverage and Service Reimbursement Updates bulletin for more details on other changes which were made to maternity coverage in October 2023.