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.

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.

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.

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.