5900, Perinatal Clinical Policy

Revision 22-2; Effective April 1, 2022

Prenatal and postpartum services must be based on American College of Obstetricians and Gynecologists (ACOG) guidelines.

Contractors may bill HHSC FPP for allowable services provided in clinical prenatal care visits for women during the Medicaid for Pregnant Women and the CHIP Perinatal Program enrollment processes. See Section 9000, Resources, Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program.

Postpartum visits that are medically necessary are reimbursable and include interval history, physical examination, assessment, family planning, counseling, education and referral, as indicated.

Components of Initial Prenatal Interventions/Screening

Prenatal Visit – The first encounter with a pregnant woman includes a complete history, physical examination, assessment, planning, treatment, counseling and education (referral as indicated), routine prenatal laboratory tests and additional laboratory tests as indicated by history, physical exam and/or assessment.

Components of Return Visit Prenatal Interventions/Screening

Return Prenatal Visit – The follow-up prenatal visit includes interval history, physical examination, risk assessment, medical services, nutritional counseling, psychosocial counseling, family planning counseling and patient education about maternal and child health topics. Hemoglobin and/or hematocrit, and urinalysis for protein and glucose are also included.

Perinatal Histories

Prenatal Visit – The comprehensive medical history documented at the initial prenatal visit must
address the following:

  • Current health status, including acute and chronic medical conditions, if any;
  • Significant past illnesses, including hospitalizations;
  • Surgeries and biopsies;
  • Blood transfusions and other exposure to blood products;
  • Mental health history (for example, depression and anxiety);
  • Current medications, including prescription, over the counter (OTC), as well as complementary and alternative medicines (CAMs);
  • Allergies, sensitivities or reactions to medicines and other substances (for example, latex or seafood);
  • Immunization status and/or assessment, including rubella status;
  • Reproductive health history;
  • Pertinent sexual behavior history, including family planning practices (that is, past contraceptive use), number of partners and gender of sexual partners;
  • Sexually transmitted infections (STIs) [including hepatitis B and C], and HIV history, risks and exposure;
  • Pertinent partner history, including injectable drug use and number of partners;
  • Menstrual history, including last normal menstrual period;
  • Obstetrical history, detailed;
  • Gynecological and urological conditions;
  • Cervical cancer screening history (date and results of last Pap test or other cervical cancer screening test, and note any abnormal results and treatment); and
  • Social history and health risk assessment including:
    • Home environment, including living arrangements;
    • Family dynamics, with assessment for family violence (including safety assessment, when indicated) [Mandated by Texas Family Code, Chapter 261 and Rider 19];
    • Tobacco, alcohol and recreational drug use or misuse and/or exposure;
    • Drug dependency (including type, duration, frequency and route);
    • Nutritional history;
    • Occupational hazards or environmental toxin exposure;
    • Ability to perform activities of daily living (ADLs); and
    • Risk assessment including, but not limited to:
      • Diabetes;
      • Heart disease;
      • Intimate partner violence;
      • Other physical or sexual abuse;
      • Human trafficking;
      • Injury;
      • Malignancy; and
      • Injury;
  • Family history, including genetic conditions; and
  • Review of systems with pertinent positives and negatives documented in the health record.

Return Prenatal Visits – The interval history includes:

  • Symptoms of infections;
  • Symptoms of preterm labor;
  • Headaches or changes in vision;
  • Fetal movement (more than 18 weeks); and
  • Family violence screening (repeat more than 28 weeks). 

Physical Assessments

All first and routine prenatal visits must include an appropriate physical exam according to the purpose of the visit and the week of gestation. For any part of the examination that is deferred, the reason or reasons for deferral must be documented in the patient health record.

First Prenatal Visit – The following measurements are taken at the first prenatal visit:

  • Height;
  • Weight, with documentation of pre-pregnancy weight and assessment for underweight, overweight and obesity;
  • Body mass index (BMI);
  • Blood pressure evaluation;
  • Cardiovascular assessment;
  • Clinical breast exam;
  • Visual inspection of external genitalia and perianal area;
  • Pelvic exam, including estimate of uterine size (by bimanual exam for gestational age of 14 weeks or less or by fundal height for gestational age of 14 weeks or more);
  • Fetal heart rate for gestational age greater than 12 weeks; and
  • Other systems, as indicated by history and health risk assessment (for example, evaluation of thyroid, lungs and abdomen).

Return Prenatal Visits – The following measurements are taken at return prenatal visits:

  • Weight;
  • Blood pressure evaluation;
  • Uterine size or fundal height;
  • Fetal heart rate (more than 12 weeks);
  • Fetal lie/position (more than 30 weeks); and
  • Other systems, as indicated by history or other findings.

Laboratory and Diagnostic Tests

All first and return prenatal visits must include appropriate laboratory and diagnostic tests as indicated by the number of weeks of gestation and clinical assessment. Contractors must have written plans to address laboratory and other diagnostic test orders, results and follow-up. to include:

  • Tracking and documentation of tests ordered and performed for each patient;
  • Tracking of test results and documentation in patient records; and
  • A mechanism to address abnormal results, facilitate continuity of care and assure confidentiality, adhering to HIPAA regulations (that is, making results and interventions accessible to the delivering hospital, facility or provider).

First Prenatal Visit Laboratory and Diagnostic Tests – The following laboratory and diagnostic tests are done at the first prenatal visit:

  • Blood type, Rh and antibody screen; and
  • Sexually transmitted infection testing, as indicated by risk assessment, history and physical exam, and the following:
    • Chlamydia and gonorrhea testing should be done on all patients age 25 or younger and on older individuals who are at an increased risk of infection, even if symptoms are not present;
    • Hepatitis B Antigen (HbsAg) [Mandated by Health and Safety Code 81.090]; and
    • HIV, unless declined by the person, who must then be referred to anonymous testing [Mandated by Health and Safety Code 81.090]. CDC recommendations are found at https://www.cdc.gov/hiv/testing/index.html Syphilis serology [Mandated by Health and Safety Code 81.090];
  • Hemoglobin and/or hematocrit;
  • Rubella serology or positive immune status/immunization documented in the chart;
  • Cervical cancer screening test (for example, Pap test) for women age 21 and older, if indicated;
  • Hemoglobinopathy screening, as indicated;
  • Urine culture;
  • TB skin test, as indicated by risk assessment, history or physical exam (see TB in specific populations). CDC: Tuberculosis (TB): Pregnancy. Available at www.cdc.gov/tb/topic/populations/pregnancy/default.htm);  
  • Ultrasound, as clinically indicated; and
  • Other laboratory and diagnostic tests, as indicated by risk assessment, history and physical exam.

Return Prenatal Visits Laboratory and Diagnostic Tests – Recommended laboratory and diagnostic tests for return prenatal visits are as follows:

  • Fetal aneuploidy screening appropriate for the gestational age at the time of testing, along with proper counseling, offered to all patients;
  • Diabetes screen (24 through 28 weeks);
  • Glucose tolerance test (GTT) for abnormal diabetic screen;
  • Antibody screen for Rh negative individuals, not previously known to be sensitized, between 24 through 28 weeks (if negative, repeat Anti-D immune globulin at about 28 weeks and, if positive, refer to a specialist in high-risk obstetrics for evaluation of possible maternal Rh-D alloimmunization);
  • Hemoglobin and/or hematocrit (recommended recheck between 32 and 36 weeks);
  • Group B streptococcus screen, between 36 0/7 and 37 6/7 weeks if using screened-based approach [see The American College of Obstetricians and Gynecologists  revised February 2020 recommendations to prevent perinatal transmission of Group B Streptococcus (GBS) infection to the neonate at ACOG: Clinical: Prevention of Group B Streptococcal Early-Onset Disease in Newborns]. Available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/02/prevention-of-group-b-streptococcal-early-onset-disease-in-newborns; 
  • Ultrasound, as clinically indicated;
  • Non-stress test to assess fetal well-being, as clinically indicated;
  • Biophysical profile or fetal biophysical profile to assess fetal well-being, as clinically indicated; and
  • Other laboratory and diagnostic tests as indicated by risk assessment, history and physical exam. 

Ultrasounds – Obstetrical ultrasounds will be reimbursed when clinically indicated, including the
following:

  • Estimation of gestational age for women with uncertain clinical dates;
  • Verification of dates for women who had a previous cesarean delivery;
  • Vaginal bleeding of undetermined origin;
  • Suspected multiple gestation;
  • Significant discrepancy between actual uterine size and expected uterine size at specific clinical dates;
  • Pelvic mass;
  • Suspected ectopic pregnancy;
  • Suspected fetal death;
  • Suspected uterine abnormality;
  • Intrauterine contraceptive device localization;
  • Abnormal alpha-fetoprotein value;
  • Follow-up observation of identified fetal anomaly;
  • Follow-up evaluation of placental location for suspected placenta previa;
  • History of congenital anomaly;
  • Serial evaluation of fetal growth in multifetal gestation;
  • Evaluation of fetal condition in late registrants for prenatal care; and
  • Other conditions associated with possible adverse fetal outcome.

Complete Ultrasound – A complete evaluation of the pregnant uterus, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Complete Ultrasound for Confirmed Multiple Gestation – A complete evaluation of the pregnant uterus that includes viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Follow-up or Limited Ultrasound – A brief, more limited evaluation of the pregnant uterus that may follow a previous complete exam, which could be a first exam before 12 weeks or a first exam at 12 weeks which is limited in scope. It includes fetal number, viability, presentation, dating measurements, limited anatomic assessment, placental localization and characterization, and amniotic fluid assessment.

Repeat D Antibody Test – For all unsensitized D-negative women at 24 through 28 weeks of gestation, followed by the administration of a full dose of D immunoglobulin if they are antibody negative. If the father is known with certainty to be Rh D-negative, this may be deferred.

Special Procedures

Nonstress Test – Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider believes the procedure to be medically necessary.

Biophysical Profile/Fetal Biophysical Profile – Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider believes the procedure to be medically necessary.

Education and Counseling Services

Contractors must have written plans for individual education that ensure consistency and accuracy of information provided and that identify mechanisms used to ensure patient understanding of the information.

Education and counseling must be:

  • Documented in the patient health record;
  • Appropriate to the person’s age, level of knowledge and sociocultural background; and
  • Presented in an unbiased manner.

Education and counseling during the first prenatal visit, based on health history, risk assessment and physical exam, must cover the following:

  • Nutrition and weight-gain counseling;
  • Family and intimate partner violence and abuse;
  • Human trafficking;
  • Physical activity and exercise;
  • Sexual activity;
  • Environmental or work hazards;
  • Travel;
  • Tobacco cessation;
  • Alcohol use;
  • Substance abuse;
  • Breastfeeding;
  • When and where to obtain emergency care;
  • Risk factors identified during visit;
  • Anticipated course of prenatal care;
  • HIV and other prenatal tests;
  • Injury prevention, including seat belt use;
  • Cocooning infants and children against pertussis (immunization of family members and potential caregivers of infant);
  • Toxoplasmosis precautions;
  • Referral to Special Supplemental Nutrition Program for Women, Infants and Children (WIC);
  • Use of medications (including prescription, over the counter (OTC), and complementary and/or alternative medicines (CAMs);
  • Information on parenting and postpartum counseling (Mandated by Chapter 161, Health and Safety Code, Subchapter T); and
  • Other education and counseling as indicated by risk assessment, history and physical exam.

Education and counseling during the return prenatal visits should be appropriate to the number of gestational weeks and be based on health history, risk assessment and physical exam, including but not limited to:

  • Signs and symptoms of preterm labor beginning in second trimester;
  • Signs and symptoms of labor as the patient nears term gestation;
  • Warning signs and symptoms of pregnancy induced hypertension (PIH);
  • Selecting a provider for the infant; and
  • Postpartum family planning.

Tobacco Assessment and Quitline Referral – All women receiving prenatal services should be assessed for tobacco use. Women who use tobacco should be referred to tobacco quit lines. The Texas American Cancer Society Quitline is 877-YES-QUIT or 866-228-4327 (hearing impaired). The assessment and referral should be performed by agency staff and documented in the clinical record.

Information for Parents of Newborns Requirement – Chapter 161, Health and Safety Code, Subchapter T, Information for Parents of Newborn Children, requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource pamphlet that includes information on postpartum depression, shaken baby syndrome, immunizations, newborn screening, pertussis and sudden infant death syndrome. In addition, it must be documented in the person's chart that they received this information, and the documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery.

Information for Parents of Children – Chapter 161, Health and Safety Code,
Subchapter T, also requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid, to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource guide that includes information relating to the development, health and safety of a child from birth until age five. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate child care.

Provision of Information about Umbilical Cord Blood Donation Requirement – Chapter 162, Health and Safety Code, Subtitle H, requires that a physician, or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant, shall provide the woman with an informational brochure before the third trimester of the woman’s pregnancy or as soon as reasonably feasible, that includes information about the uses, risks and benefits of cord blood stem cells for a potential recipient, options for future use or storage of cord blood, the medical process used to collect cord blood, any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery and average cost of public and private storage. The brochure is available at https://www.dshs.state.tx.us/mch/. 

Education and counseling during postpartum visits should include, but not be limited to:

  • Physiological changes;
  • Signs and symptoms of common complications;
  • Care of the breast;
  • Care of perineum and abdominal incision, if indicated;
  • Physical activity and exercise;
  • Breastfeeding and infant feeding;
  • Resumption of sexual activity;
  • Family planning and contraception;
  • Preconception counseling; and
  • Depression and postpartum depression.

Referral and Follow-up

Agencies must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to patients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information.

For necessary services that are beyond the scope of the agency, patients must be referred to other providers for care. Whenever possible, patients should be given a choice of providers from which to select. When a patient is referred to another provider or for emergency clinical care, the agency must:

  • Provide pertinent individual information to the referral provider and obtaining required patient consent with proper safeguards to ensure confidentiality (that is, adhering to HIPAA regulations);
  • Advise the individual about his or her responsibility to comply with the referral; and
  • Counsel the individual about the importance of the referral and follow-up plan.