Prenatal Care Provided by Primary Care Physicians

Number: 0047

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses prenatal care provided by primary care physicians.

1. Medical Necessity

   Notes: Aetna members may choose to remain with their qualified family physician for delivery or for prenatal care only.  The following policy applies to family physicians providing only prenatal care:
   
   All family practices that provide prenatal services to their patients must identify themselves to Aetna and must agree to abide by Aetna policies for this care.
   
   The pregnant Aetna member must be offered the choice of prenatal care by either the practice or a participating obstetrician.
   
   When a member chooses to remain in the primary care practice for prenatal care, the following must occur:

   1. All genetic testing will be coordinated through the Aetna Beginning Right Maternity Program.
   2. Primary care physicians providing only prenatal care should bill for the prenatal visits they have provided using CPT Code 59425 (antepartum care only; 4 to 6 visits) or CPT Code 59426 (antepartum care only; 7 or more visits), and will be reimbursed according to Aetna's fee schedule.
   3. The member must choose a participating obstetrician as a co-manager of her care.
   4. The member will be referred to her selected obstetrician for continuing care and delivery no later than the 28th week visit. The member's complete prenatal record must be available at this visit.
   5. The member will be referred to the selected obstetrician for all limited ultrasound and fetal non-stress testing.
   6. The practice will be responsible to present a fetal aneuploidy screening consent form to the member for accept/decline signature in the first trimester.
   7. The practice will enroll the member in Aetna's Beginning Right Maternity Program.
   8. The practice will refer the member to her selected obstetrician for a first trimester educational visit.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
59025	Fetal non-stress test
59425	Antepartum care only; 4-6 visits
76801 - 76817	Obstetrical ultrasound
76818	Fetal biophysical profile; with non-stress testing
82105, 82106	Alpha-fetoprotein; serum, or amniotic fluid
88271 - 88275	Molecular cytogenetics
88291	Cytogenesis and molecular cytogenesis, interpretation and report
ICD-10 codes covered if selection criteria are met:
O09.00 - O09.93, Z34.00 - Z34.93	Supervision of pregnancy [normal and high risk]

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Background

Many family physicians in our network are trained and qualified to provide obstetric care.  This policy will assure high-quality prenatal care for Aetna members while allowing family physicians the opportunity to continue their care through the 27th week of pregnancy.

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References