SECTION 317:30-5-22. Obstetrical care

(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 obstetrical care. Inclusive dates of care should be indicated on the claim form as part of the description. Payment for total obstetrical 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 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 obstetrical 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 Prenatal Psychosocial Assessment are reimbursable when both documents are included in the prenatal record. SoonerCare allows one assessment per provider and no more than two per pregnancy.

(2)   Medically necessary real time antepartum diagnostic ultrasounds will be paid in addition to antepartum care, delivery and postpartum obstetrical 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 abdominal or vaginal ultrasound will be covered in the first trimester of pregnancy. 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, Family Practice Physician or Advance Practice Nurse Practitioner in Obstetrics with a certification in obstetrical ultrasonography.

(B)   One 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 Certified Nurse Midwife, Family Practice Physician or Advance Practice Nurse Practitioner in Obstetrics with certification in obstetrical ultrasonography.

(C)   One 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 obstetrical 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 OAC 317:30-5-8.

(6)   Additional payment is not made for the delivery of multiple gestations. If one 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 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).

(c)   Assistant surgeons are paid for C-Sections which include only in-hospital post-operative care. Family practitioners who provide prenatal care and assist at C-Section bill separately for the prenatal and the six weeks postpartum office visit.

(d)   Procedures listed in (1) - (5) of this subsection are not paid or not covered separately from total obstetrical care.

(1)   Non stress test, unless the pregnancy is determined medically high risk. See OAC 317:30-5-22.1.

(2)   Standby at C-Section is not compensable when billed by a physician participating in delivery.

(3)   Payment is not made for an assistant surgeon for obstetrical procedures that include prenatal or postpartum care.

(4)   An additional allowance is not made for induction of labor, double set-up examinations, fetal stress tests, or pudendal anesthetic. Providers must not bill separately for these procedures.

(5)   Fetal scalp blood sampling is considered part of the total OB care.

(e)   Obstetrical coverage for children is the same as for adults. Additional procedures may be covered under EPSDT provisions if determined to be medically necessary.

(1)   Services deemed medically necessary and allowable under federal Medicaid regulations are covered by the EPSDT/OHCA Child Health Program even though those services may not be part of the Oklahoma Health Care Authority SoonerCare program. Such services must be prior authorized.

(2)   Federal Medicaid regulations also require the State to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or which are considered experimental.

[Source: Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 14 Ok Reg 2394, eff 5-28-97 (emergency); Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 16 Ok Reg 3413, eff 7-1-99 (emergency); Amended at 17 Ok Reg 708, eff 1-10-00 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 21 Ok Reg 2176, eff 6-25-04; Amended at 24 Ok Reg 207, eff 11-1-06 (emergency); Amended at 24 Ok Reg 895, eff 5-11-07; Amended at 25 Ok Reg 426, eff 11-1-07 (emergency); Amended at 25 Ok Reg 658, eff 1-1-08 (emergency); Amended at 25 Ok Reg 1161, eff 5-25-08; Amended at 26 Ok Reg 100, eff 8-1-08 (emergency); Amended at 26 Ok Reg 254, eff 12-1-08 (emergency); Amended at 26 Ok Reg 1059, eff 5-11-09; Amended at 26 Ok Reg 1766, eff 7-1-09 (emergency); Amended at 27 Ok Reg 108, eff 10-2-09 (emergency); Amended at 27 Ok Reg 946, eff 5-13-10; Amended at 32 Ok Reg 729, eff 7-1-15 (emergency); Amended at 32 Ok Reg 1050, eff 8-27-15; Amended at 32 Ok Reg 731, eff 8-27-15 (emergency); Amended at 33 Ok Reg 801, eff 9-1-16; Amended at 34 Ok Reg 192, eff 11-22-16 (emergency); Amended at 34 Ok Reg 657, eff 9-1-17]