HEDIS® Tip Sheet

Prenatal & Postpartum Care (PPC)

Line of business: BlueAlliance (Commercial) 

Measure Description

The percentage of deliveries of live births on or between October 8 of the year prior to the measurement year and October 7 of the measurement year.

The measure is assessed by the following:

  • Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit in the first trimester.
  • Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery.
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Notes

  • First Trimester is defined as 280-176 day prior to delivery or the estimated delivery date (EDD).
  • Multiple births:  Members 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 count twice.
  • Members who had multiple live births during one pregnancy count once (e.g., pregnancy with twins).
  • If a member has more than one delivery in a 180-day period, include only the first eligible delivery.
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Prenatal Visits

  • Visit must take place in the first trimester or within 42 days of enrollment with BCBSND coverage.
  • The last menstrual period (LMP) may not be used to determine first trimester; must be determined with EDD. 
  • Visit must be with an OB/GYN, other prenatal care practitioner, or PCP.
  • Ultrasounds and lab visits alone are not considered a visit.
  • Any of the following meet criteria: 
    • Prenatal Care Visit with a pregnancy related diagnosis code.
    • Bundled service including the date when the prenatal care was initiated. 

Medical Records for Prenatal Visit must include:

  • Visits with a PCP must have a diagnosis of pregnancy.
  • Prenatal Care documentation must include the date the prenatal care visits occurred and evidence of one of the following:
    • Documentation indicating the member is pregnant or references to the pregnancy in the medical record such as:
      • Prenatal flowsheet; or
      • Last menstrual period (LMP), EDD, or gestational age; or
      • Positive pregnancy test results; or
      • Gravidity and parity; or
      • Complete obstetrical history; or
      • Prenatal risk assessment and counseling/education.
    • Physical obstetrical examination that includes fetal heart tone or pelvic exam with obstetrical observations, or fundus heigh measurement.
    • Evidence that prenatal care was done:
      • Obstetrical panel or
      • Torch antibody panel alone, or
      • Rubella antibody test/titer with an RH incompatibility blood typing, or ultrasound of pregnant uterus.
      • Ultrasound of pregnant uterus. 

Exclusions:

  • Pregnancies that do not result in a live birth.
  • Members in hospice during the measurement year.
  • Member who died during the measurement year.

Prenatal Best Practices

  • Educate patients on the importance of the prenatal/initial visit.
  • Connect patients to resources for family assistance programs.
  • Encourage patients to maintain the relationship with an OB/GYN to promote consistent and coordinated health care.
  • Educate patients on the importance of keeping each prenatal visit.
  • Consider offering extended practice hours to increase care access.
  • Remind patients of their appointment by making calls, sending texts, and their patient portal.
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Postpartum Care

  • Visit must take place on or between 7 and 84 days after delivery.
  • Postpartum care must occur with an OB/GYN, other prenatal care practitioner, or a PCP.
  • Postpartum care in an acute inpatient setting cannot be included.
  • Any of the following meet criteria: 
    • Postpartum visit.
    • Cervical Cytology
    • Bundled service including the date when the postpartum care was rendered.

Medical Records for Postpartum Care must include:

  • Postpartum Care documentation must include the date the postpartum care visit occurred and evidence of one of the following:
    • Pelvic Exam
      • A pap test is considered evidence of a pelvic exam.
    • Evaluation of weight, blood pressure, breasts, and abdomen.
    • Perineal or cesarean incision wound check.
    • Screening for depression, anxiety, tobacco use, substance use, or preexisting mental health disorder.
    • Glucose screening for members with gestational diabetes.
    • Documentation on the following topics:
      • Infant care/breastfeeding.
      • Sleep/fatigue
      • Resuming physical activity
      • Healthy weight.
      • Resuming intercourse, birth spacing, family planning.

Exclusions:

  • Pregnancies that do not result in a live birth.
  • Postpartum services provided in an acute inpatient setting.
  • Members in hospice during the measurement year.
  • Member who died during the measurement year.

Postpartum Best Practices:

  • Educate patients on the importance of a postnatal visit.
  • Review the visit schedule with the patient prior to discharge from inpatient care.
  • Connect patients to resources for family assistance programs.
  • Encourage patients to maintain the relationship with an OB/GYN or PCP.
  • Consider offering extended practice hours to increase care access.
  • Schedule the postpartum visit prior to discharge from the hospital. 
  • Remind patients of their appointment by making calls or sending texts, and their patient portal.
  • Make outreach calls and/or send letters to advise members of the need for a visit.

Coding Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.

Questions  

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

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