Hints for HEDIS
Prenatal and postpartum care (PPC)
We are committed to working with you to improve the quality of care and health outcomes for our members, your patients. The Healthcare Effectiveness Data and Information Set (HEDIS®) is one tool we use to measure many aspects of performance. The information below details some of the key features of the HEDIS measure for prenatal and postpartum care (PPC).
What is the measure?
The measure examines two rates:
- A prenatal timeliness rate, which is the percentage of deliveries that received a prenatal care visit as a member in the first trimester, on the enrollment start date or within 42 days of enrollment
- A postpartum rate, which is the percentage of deliveries that received postpartum care on or between seven and 84 days after delivery
- Members who delivered (a live birth) on or between October 8 of the year prior to the measurement year and October 7 of the measurement year
- Women who delivered in any setting
- Women who had two separate deliveries (different dates of service) between October 8 of the year prior to the measurement year and October 7 of the measurement year are counted twice
- Women who had multiple live births during one pregnancy are to be counted only once
Codes for visit types
Any one of the following during the first trimester:
Prenatal bundled services
CPT: 59400, 59510, 59425, 59426, 59610, 59618
Stand-alone prenatal visits
CPT: 99500, 0500F. 0501F, 0502F
HCPCS: H1000, H1001, H1002, H1003, H1004
Any one of the following:
CPT: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175
HCPCS: G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091
CPT: 57170, 58300, 59430, 99501, 0503F
ICD10: Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2
Postpartum bundled services
CPT: 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622
Acceptable forms of documentation
Timeliness of prenatal care: Had a prenatal care visit in the first trimester (12 weeks), on or before the enrollment start date, or within 42 days of enrollment with BCBSRI.
Prenatal care visit to an OB/GYN or other prenatal care practitioner or primary care physician (PCP). For visit to a PCP, a diagnosis of pregnancy must be present.
Documentation in the medical record must include a note indicating the date when the prenatal visit occurred and evidence of one of the following:
- A diagnosis of pregnancy
- A basic physical obstetrical exam that includes one of the following:
- Auscultation for fetal heart tone
- Pelvic exam with obstetric observations
- Measurement of fundus height (a standardized prenatal flow sheet may be used)
- Evidence that a prenatal care procedure was performed, such as one of the following:
- Screening test in the form of an obstetric panel, which must include all of the following: Hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody syphilis test, RBC antibody screen, Rh and ABO blood typing
- TORCH antibody panel alone (toxoplasma, rubella, cytomegalovirus, herpes simplex)
- Rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing
- Ultrasound of a pregnant uterus
- Documentation of LMP, EDD, or gestational age in conjunction with either of the following:
- Prenatal risk assessment and counseling/education
- Complete obstetrical history
Postpartum care: Had a postpartum visit to an OB/GYN practitioner or midwife, family practitioner or other PCP on or between seven and 84 days following delivery of live birth. Documentation in the medical record must include a note indicating the date when a postpartum visit occurred and one of the following:
- Pelvic exam. A Pap test is acceptable as evidence of a pelvic exam for postpartum care rate.
- Evaluation of weight, blood pressure, breasts, and abdomen. A notation of breastfeeding is acceptable for the evaluation of breasts component.
- Notation of postpartum care, including but not limited to postpartum care, PP care, PP check, or six-week check; or a preprinted postpartum care form in which information was documented during the visit.
- Perineal or cesarean incision/wound check.
- Screening for depression, anxiety, tobacco use, substance use disorder, or preexisting mental health disorders.
- Glucose screening for women with gestational diabetes.
- Documentation of any of the following: Resumption of intercourse; sleep/fatigue; resumption of physical activity, and attainment of healthy weight; infant care or breastfeeding; birth spacing or family planning.
How to improve the measure
- When scheduling an initial prenatal visit, do not delay. It must take place in the first 12 weeks of pregnancy with an OB/GYN, PCP, or other prenatal practitioner.
- When documenting a prenatal visit, include diagnosis of pregnancy, LMP or EDD, and notate evidence of prenatal care such as prenatal risk assessment, complete obstetrical history, fetal heart tone, screening tests, etc.
- When scheduling an after-delivery follow-up visit, a post-operative visit following a Caesarean section that takes place within a couple days of discharge count as a postpartum visit. A postpartum visit must take place on or between 21and 56 days after delivery. A postpartum visit should be scheduled during the cesarean section post-operative visit.
- When documenting the postpartum visit, notate postpartum care, PP care, PP check, or six-week check. It can be a simple note, documenting pelvic exam, evaluation of weight, blood pressure, breasts, and abdomen. Breastfeeding notation is acceptable for the breast evaluation. Visit must be with OB/GYN practitioner or midwife, family practitioner, or other PCP.
- Deliveries resulting in non-live births.
- Members in hospice.