PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: HKUP3076 (previously MPUP3076 &
Lead Department: Health Services
KK UM111)
Policy/Procedure Title: Health Services Review of Non-admission
External Policy
In-hospital Obstetrical Evaluations
Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to:
Medi-Cal
Healthy Kids
Employees
Reviewing
Entities:
IQI
P&T
QUAC
OPERATIONS
EXECUTIVE
COMPLIANCE
DEPARTMENT
Approving
Entities:
BOARD
COMPLIANCE
FINANCE
PAC
CEO
COO
Approval Signature: Robert Moore, MD, MPH
CREDENTIALING
DEPT. DIRECTOR/OFFICER
Approval Date: 08/19/2015
I.
RELATED POLICIES:
A. HKUG3120 - Prenatal and Perinatal Care for Commercial Members
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
This policy defines the criteria and guidelines for use of the “S4005” code and for observation codes used for
PHC obstetrical Healthy Kids members in Solano County only.
VI.
POLICY / PROCEDURE:
A. A labor check is defined as an in-hospital evaluation of a pregnant woman beyond 20 weeks from the
LMP who present with a complaint of uterine contractions or suspected rupture of membranes. Claims
for labor checks are considered only if the woman is evaluated and discharged. If a woman is admitted
to the hospital based upon the findings at the labor check, the labor check visit is considered to be a
component of the inpatient stay and is not paid as a separate claim. For the purposes of claims submitted
to PHC for labor checks, the following applies:
1. Labor checks are to be billed with Code “S4005” if services are 1 hour or less and is an all-inclusive
code and rate.
2. Labor checks include:
a. Check-in and interval history
b. Fetal monitor strip (not full NST)
c. Cervix check; sterile speculum exam if necessary
d. Urine dipstick for protein, if performed
e. Sonogram for fetal position and FHR, as needed
Page 1 of 3
Policy/Procedure Number: MPUP3076 (previously
Lead Department: Health Services
HKUP3076 & KK UM111)
☒External Policy
Policy/Procedure Title: Health Services Review of Nonadmission In-hospital Obstetrical Evaluations
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
3. PHC pays for up to three labor checks per member per 24 hour period. A single labor check can be
billed per confinement in L&D; multiple claims for labor checks are not paid if provided during the
same confinement.
4. Non-stress tests, contraction stress tests, and routine prenatal labs are not paid if provided during a
labor check. Lab services are paid if medically necessary.
5. If a labor check requires observation for over one hour or if evaluation of a potential medical or
obstetrical problem is necessary, the claim must be submitted as an observation claim (Z7514) rather
than a labor check; see D.2. below.
B. When a pregnant woman beyond 20 weeks from the LMP is evaluated in labor and delivery for an urgent
obstetrical condition other than active contractions or suspected rupture of membranes, only the
observation code should be used and not the labor check code.
1. During the observation period, individual interventions such as stress and non-stress tests, diagnostic
ultrasound evaluations, and non-routine laboratory tests may be ordered and then billed to PHC.
2. PHC reviews for medical necessity all claims submitted for "observation" of obstetrical patients.
The medical record pertaining to the observation period must be submitted with the claim.
C. Obstetrical patients seen in the context of a labor check may require observation for a time period
beyond one hour to determine whether labor is present or in order to evaluate a potential medical or
obstetrical problem. In this case, the claim should be submitted with the observation code (with the
number of observation units indicated), and not as a labor check. Individual interventions may be
ordered and billed to PHC as above.
D. In some of the hospitals contracted with PHC, pregnant patients over a specified gestational age (usually
20 weeks LMP) are referred to L&D, rather than the emergency department, for evaluation of nonobstetrical problems, as well as those related to pregnancy.
1. Claims for urgent problems not requiring either a labor check or observation are paid at the
emergency department or urgent care visit rate.
2. Claims for emergent problems are paid on a fee for service basis. If an observation period is
necessary beyond the time needed for initial patient evaluation, the "observation" billing code
(Z7514) may be used.
3. The same diagnosis and procedure codes used to differentiate between emergent and urgent care
visits in the emergency department are used for non-obstetrical evaluations.
E. Non-contracted hospitals, which bill, should use CPT 99218 for labor checks. This includes all services
outlined above. If the provider bills for more than one labor check, it should be coded as Z7514
(observation) with appropriate number of units, all related services provided and attach a copy of the
medical records. Claims will be subject to review by the Health Services Department prior to payment.
VII.
REFERENCES:
A. N/A
VIII.
DISTRIBUTION:
A. PHC Department Directors,
B. PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
Page 2 of 3
Policy/Procedure Number: MPUP3076 (previously
Lead Department: Health Services
HKUP3076 & KK UM111)
☒External Policy
Policy/Procedure Title: Health Services Review of Nonadmission In-hospital Obstetrical Evaluations
☐Internal Policy
Next Review Date: 08/19/2016
Original Date: 11/16/2005
Last Review Date: 08/19/2015
Applies to: ☐ Medi-Cal
☒ Healthy Kids
☐ Employees
X.
REVISION DATES:
Healthy Kids
11/21/07; 11/19/08; 06/16/10; 10/01/10; 08/19/15
PREVIOUSLY APPLIED TO:
Healthy Families:
MPUP3076 - 10/01/2010 to 03/01/2013
Page 3 of 3