Prenatal tests & immunizations

Applies to members of:

All plans, except self-funded plans with a Maternity exclusion for dependents

Clinical Practice Guideline

Routine maternity services coverage

Routine maternity services are not synonymous with preventive benefit with no cost share. Consult plan documents for specific routine maternity benefits. 

Self-funded plans with a Maternity exclusion for dependents will deny all services except routine lab work.

Clinical edit: Obstetric Services, Global Care

Claims will deny Evaluation and Management services (99202-99215) when billed with a diagnosis of post-partum care uncomplicated postpartum care (ICD-10 codes Z39-Z39.2), contraceptive management (ICD-10 codes Z30.011, Z30.013-Z30.09), or family planning advice when a delivery care only service (59409, 59514, 59612, 59620) has been billed in the past 42 days (6 weeks) by any provider.

AMA CPT manual instructs postpartum care cannot be reported as a separate E/M service during the postpartum period, whether performed by the same provider who performed the delivery or by a different provider. Postpartum care is correctly reported.

Prenatal test and immunization billing

Bacteriuria screening

  • Use codes 81000-81003, diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • At 12-16 weeks gestation or first prenatal visit
  • USPSTF Rating: A

Blood tests

Complete blood count:

  • 85025*, 85027*
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • On a routine basis for iron deficiency anemia

Blood typing:

  • 86900*
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

Gestational diabetes screening:

  • 82947, 82948, 82950, 82951, 82952
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • For women 24-28 weeks pregnant and those at high risk for gestational diabetes
  • USPSTF Rating: B
  • HRSA requirement

Hemoglobin/hematocrit:

  • 85014*, 85018*
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • On first prenatal visit

Hepatitis B screening:

  • 86704, 86340*
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • USPSTF Rating: A

Obstetric panel:

  • 80055, 80081
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • Priority Health routine pre-natal care as preventive

RBC antibody screen:

  • 86850*
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

Rh compatibility:

  • 86901
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • First prenatal visit and follow up for women at high risk
  • USPSTF Rating: A

Rubella antibody:

  • 86762*
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • USPSTF Rating: B

Venipuncture:

  • 36415, 36416
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • Bill with preventive blood studies

Cervical cancer screening/Pap smear

  • 88141-88155, 88164-88167, 88174,88175
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • HRSA requirement

HIV testing

  • 86701, 86702, 86703, 87806
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • USPSTF Rating: A

Syphilis testing

  • 86592*
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • USPSTF Rating: A

Gonorrhea testing

  • 87850, 87590, 87591, 87592
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • USPSTF Rating: B

Chlamydia testing

  • 87110, 87270, 87320, 87490, 87491, 87492
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2
  • USPSTF Rating: B

Human Papillomavirus (HPV) testing

  • 87623, 87624, 87625
  • Diagnosis codes O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

Ultrasound

  • 76801 - 76817
  • No diagnosis codes specified
  • Priority Health routine pre-natal care as preventive

Vaccinations

No diagnosis codes are specified for vaccinations.

Administration:

Hepatitis A, B:

  • 90632-90636, 90740-90747
  • Administer during pregnancy if at risk

Influenza injection (excludes nasal spray):

Meningococcal:

  • 90620, 90621, 90733, 90734
  • If indicated during pregnancy

Pneumococcal:

  • 90670, 90732
  • If indicated during pregnancy

Tetanus, diphtheria, whooping cough:

  • 90702, 90714, 90715
  • One dose recommended during pregnancy

*Test included in OB Panel; screening is typically performed using the OB panel