For Dates of Service On and After October 1, 2015

Diagnosis Codes on Claims for Prenatal Care Coordination Services

Claims submitted for PNCC services must include one of the following ICD diagnosis codes as the primary diagnosis associated with the procedure:

• Z33.1 (Pregnanat state, incidental)
• O09.90 (supervision of high risk pregnancy, unspecified, unspecified trimester)
• O09.91 (supervision of high risk pregnancy, unspecified, first trimester)
• O09.92 (supervision of high risk pregnancy, unspecified, second trimester)
• O09.93 (supervision of high risk pregnancy, unspecified, third trimester)

Providers are required to indicate the following diagnosis codes on claims for PNCC services:

• Z33.1 when submitting a claim on behalf of a member who does not meet the enrollment criteria (i.e., those who are assessed but determined ineligible to receive services). Diagnosis code Z33.1 may only be used with procedure code H1000.
• O09.90–O09.93 when submitting a claim on behalf of a member who scores four or more points on the Pregnancy Questionnaire or is under 18 years of age (i.e., those who are determined eligible to receive services).
• O09.90–O09.93 when submitting claims with procedure codes H1000, H1002 and modifier "U2," H1003, H1003 and modifier "TT," H1004, and T1016 and modifier "TH." Providers are required to indicate O09.90 (supervision of high risk pregnancy, unspecified, unspecified trimester), if the gestational age is unknown.

ForwardHealth will deny claims if providers indicate diagnosis codes other than the diagnosis codes listed above as the primary diagnosis when submitting claims for PNCC services. Providers may use additional ICD diagnosis codes in the secondary positions as appropriate.