Maryland Medicaid Program OB/GYN Services Obstetrical Care

OB/GYN Services August 2023 Page 1 of 5

Maryland Medicaid Program

OB/GYN Services

Obstetrical Care

Most pregnant members enrolled in Medicaid must enroll in HealthChoice, Medicaid’s managed care

program. HealthChoice beneficiaries who do not select a managed care organization (MCO) are auto-

assigned to an MCO. For additional information about HealthChoice, go to

https://mmcp.health.maryland.gov/healthchoice/Pages/Home.aspx.

Pregnant members often access care on a fee-for-service basis prior to enrollment in the MCO. This

occurs because some members apply for Medicaid during pregnancy or are only eligible for Medicaid

because they are pregnant. Certain members are not eligible for MCO enrollment. For example,

members with temporary Hospital Presumptive Eligibility coverage and members with dual coverage

(Medicare and Medicaid) will not be enrolled in MCOs.

Providers must check EVS at each visit prior to rendering services to determine if the beneficiary is

enrolled in an MCO. Providers who are contracted with MCOs should refer to the MCO’s provider

contract, provider manual, preauthorization procedures and billing instructions. Go to the

HealthChoice Provider Brochure for MCO contact information at

https://health.maryland.gov/mmcp/healthchoice/Documents/HealthChoice_Provider_Brochure_Augu

st%202023.pdf

Self-Referral Provisions and Continuity of Care

•

If a pregnant member has initiated prenatal care with an out-of-network provider prior to

MCO enrollment, they may continue to see that provider during their pregnancy. The

provider must be willing to bill the MCO. See Factsheet #1.

•

When accessing self-referral services, beneficiaries must use in-network pharmacy and

laboratory services.

•

The MCO is required to reimburse an out-of-network provider at the Medicaid fee for

service rate.

•

Continuity of Care provisions also require MCOs to allow newly enrolled members to

continue to see an out of network provider when the member has already initiated prenatal

care.

•

Medically necessary services related to prenatal care such as lab tests, prenatal vitamins and

prescription drugs, sonograms, and non-stress tests are covered.

•

Prenatal care providers must use the appropriate evaluation and management code (E&M)

in conjunction with the appropriate ICD-10 pregnancy code for each prenatal visit.

Factsheet #7

OB/GYN Services August 2023 Page 2 of 5

•

Medicaid does not reimburse physicians for “global” maternity care services.

Providers must bill deliveries separately from prenatal care.

CPT Code Description

99201 Office visit, new patient, minimal

99202 Office visit, new patient, moderate

99203 Office visit, new patient, extended

99204 Office visit, new patient, comprehensive

99205 Office visit, new patient, complicated

99211 Office visit, established patient, minimal

99212 Office visit, established patient, moderate

99213 Office visit, established patient, extended

99214 Office visit, established patient, comprehensive

99215 Office visit, established patient, complicated

Maryland Prenatal Risk Assessment Process

The Program will reimburse prenatal care providers an additional fee for completion of the Maryland

Prenatal Risk Assessment (MPRA). See page 5 for sample MPRA. Use HCPCS code H1000. (The

program does not use code 99420.) Only one risk assessment per pregnancy will be

reimbursed. To complete the MPRA process, providers must:

1) Fill out the MPRA form (DHMH 4850) at the first prenatal visit;

2) Fax the form to the local health department (addresses and fax numbers are on the form); and

3) Develop a plan of care based on the member’s risk factors.

•

The MPRA identifies members at risk for low birth weight, pre-term delivery and other

health care conditions that may put the member and/or infant at risk.

•

The local health departments use the MPRAs to identify members who may benefit from

local programs, or who may need assistance navigating the health care system.

•

LHDs are required to forward the MPRAs to the MCO.

•

The MCOs use the MPRAs to identify members that are pregnant and link them to care

coordination and case management services.

To retrieve the Maryland Prenatal Risk Assessment, go to

https://health.maryland.gov/mmcp/Pages/Provider-Information.aspx

Enriched Maternity Services

The Program will reimburse prenatal care providers an additional fee when “enriched” maternity

services are provided. Use HCPCS code H1003. (The Program does not use codes 99411 and

99412.) Only one unit of service per prenatal and postpartum visit will be reimbursed. An

“Enriched Maternity Service” must include all the following:

1) Individual prenatal health education;

2) Documentation of topic areas covered (see page 7 for sample Enriched Maternity Services);

3) Health counseling; and

4) Referral to community support services.

The completed EMS form must be completed and kept in the patient's record. The form can be form

here: https://health.maryland.gov/mmcp/Pages/Provider-Information.aspx

OB/GYN Services August 2023 Page 3 of 5

SBIRT (Screening, Brief Intervention, and Referral to Treatment)

The Program will reimburse for SBIRT intervention codes W7000, W7010, W7020, W7021, and

W7022 in conjunction with an office visit. When billing with H1003, the provision of this service

must be in addition to the alcohol and substance use counseling component of the “Enriched

Maternity Service.”

The Program will reimburse separately for smoking and tobacco use cessation counseling codes

99406 and 99407. However, when billing with H1003, the provision of this service must be in

addition to the smoking and tobacco use/cessation counseling component of the “Enriched

Maternity Service.”

For more information about SBIRT (Screening, Brief Intervention, and Referral to Treatment), go to:

https://health.maryland.gov/bha/Pages/SBIRT.aspx

Intrapartum & Postpartum Care

•

Providers must bill deliveries separately from prenatal care. The Program does not use

procedure codes 59400, 59425, 59426, 59510, and 59610.

•

If other procedures are performed on the same date of service, list the code for delivery on

the first line of Block 24 of the CMS-1500 form. List the modifier in column 24D for the

second or subsequent procedure.

•

For vaginal deliveries performed in a “home” or “birthing center”, use codes 59410 and

59614, with the appropriate place of service code “12 or 25” indicated in Block 24B of the

CMS-1500 form. Use the unlisted maternity care and delivery code 59899 for supplies used

for a vaginal delivery.

•

Use code 59430 for postpartum care services only. Postpartum care includes all visits in

the hospital and office after the delivery. Postpartum care is not payable as a separate

procedure unless it is provided by a physician or group other than the one providing the

delivery service.

Refer to the Program’s Professional Services Provider Manual and CMS-1500 Billing Instructions on the

Program’s website:

https://mmcp.health.maryland.gov/Pages/Provider-Information.aspx

Maternal and Child Health Programs

Medicaid has created several new or enhanced maternal and child health (MCH) initiatives that were

implemented in January 2022. Programs and services include:

• Doula services

• Home visiting services

• MOM (Maternal Opioid Misuse) case management services

Additional information about these programs and services can be found at the following link:

https://health.maryland.gov/mmcp/medicaid-mch-initiatives/Pages/Home.aspx

Expanded Medicaid coverage for postpartum members

Effective April 1, 2022, Medicaid expanded coverage for pregnant beneficiaries. Medicaid-eligible

pregnant members will be able to access full Medicaid benefits for the duration of their pregnancy and

OB/GYN Services August 2023 Page 4 of 5

the 12-month postpartum period.

Gynecology

Use the appropriate Preventive Medicine codes for routine annual gynecologic exams:

99383 - 99387 for new patients

99393 - 99397 for established patients

Use the appropriate E&M codes for problem-oriented visits:

99201 - 99205 for a new patient

99211 - 99215 for an established patient

Providers may only bill the Program for laboratory procedures which they perform or are performed

under their direct supervision. Physicians’ service providers cannot be paid for clinical laboratory

services without both a Clinical Laboratory Improvement Amendment (CLIA) certification and

approval by the Maryland Laboratory Administration, if located in Maryland. Laboratory procedures

that the physician refers to an outside laboratory or practitioner for performance must be billed by

that laboratory or practitioner.

Interpretation of laboratory results or the taking of specimens other than blood is considered part

of the office visit and may not be billed as a separate procedure. Specimen collection for Pap

smears is not billable by a physician. For specific information regarding pathology and laboratory

services, refer to the Medical Laboratories Provider Fee Schedule at

https://mmcp.health.maryland.gov/pages/Provider-Information.aspx. For additional information,

contact Physicians Services at 410-767-1462.

Hysterectomy

Medicaid will pay for a hysterectomy only under the following conditions:

•

The physician who secured authorization to perform the hysterectomy has informed the

member and their representative, if any, both orally and in writing, that the hysterectomy

will render the member permanently incapable of reproducing; AND

•

The member or their representative, if any, has signed a written acknowledgment of receipt

of that information (patients over the age of 55 do not have to sign); OR

•

The physician who performs the hysterectomy certifies, in writing, that either the member

was already sterile at the time of the hysterectomy and states the cause of the sterility; OR

•

The hysterectomy was performed under a life-threatening emergency situation in which

the physician determined that prior acknowledgment was not possible, and the physician

must include a description of the nature of the emergency.

The Program will not pay for a hysterectomy performed solely for the purpose of rendering an

individual permanently incapable of reproducing. Hysterectomies are also prohibited when

performed for family planning purposes even when there are medical indications that alone do not

indicate a hysterectomy.

OB/GYN Services August 2023 Page 5 of 5

Regulations require physicians who perform hysterectomies (not secondary providers, e.g.,

assisting surgeons or anesthesiologists) to complete the “Document for Hysterectomy” form

(DHMH 2990), which is available at: https://mmcp.health.maryland.gov/Pages/Provider-

Information.aspx. The completed DHMH 2990 must be kept in the patient’s medical record.

For a list of procedure codes, refer to the FFS Program’s Professional Services Provider Manual at

https://mmcp.health.maryland.gov/Pages/Provider-Information.aspx.

Hospital Admissions

Preauthorization by Telligen, the Program’s Utilization Control Agent (UCA) is required for all elective

hospital admissions for recipients covered under Medicaid’s fee-for-service program. It is the hospital’s

responsibility to obtain preauthorization by using Qualitrac to submit level of care

requests. For more information regarding Qualitrac, go to https://telligenmd.qualitrac.com/ or call

at 888-276-7075.

For questions regarding Medicaid’s reproductive health services, contact the Division of

Community Liaison and Care Coordination at 410-767-3605.