Clinical Policy Bulletin: Prenatal Care Provided by Primary Care Physicians
Notes: Aetna members may choose to remain with their qualified family physician for delivery or for prenatal care only. The following policy applies to family physicians providing only prenatal care:
All family practices that provide prenatal services to their patients must identify themselves to Aetna and must agree to abide by Aetna policies for this care.
The pregnant Aetna member must be offered the choice of prenatal care by either the practice or a participating obstetrician.
When a member chooses to remain in the primary care practice for prenatal care, the following must occur:
All genetic testing will be coordinated through the Aetna Beginning Right Maternity Program.
Primary care physicians providing only prenatal care should bill for the prenatal visits they have provided using CPT Code 59425 (antepartum care only; 4 to 6 visits) or CPT Code 59426 (antepartum care only; 7 or more visits), and will be reimbursed according to Aetna's fee schedule.
The member must choose a participating obstetrician as a co-manager of her care.
The member will be referred to her selected obstetrician for continuing care and delivery no later than the 28th week visit. The member's complete prenatal record must be available at this visit.
The member will be referred to the selected obstetrician for all limited ultrasound and fetal non-stress testing.
The practice will be responsible to present a fetal aneuploidy screening consent form to the member for accept/decline signature in the first trimester.
The practice will enroll the member in Aetna's Beginning Right Maternity Program.
The practice will refer the member to her selected obstetrician for a first trimester educational visit.
Many family physicians in our network are trained and qualified to provide obstetric care. This policy will assure high-quality prenatal care for Aetna members while allowing family physicians the opportunity to continue their care through the 27th week of pregnancy.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met: :
76801 - 76817
88271 - 88275
ICD-9 codes covered if selection criteria are met: :
V22.0 - V23.9
Supervision of pregnancy [normal and high risk]
The above policy is based on the following references:
American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG). AAFP--ACOG joint statement of cooperative practice and hospital privileges. Am Fam Physician. 1998;58(1):277-278.
American Academy of Family Physicians. Maternity and gynecologic care. Recommended core educational guidelines for family practice residents. Am Fam Physician. 1998;58(1):275-277.
Mengel MB, Phillips WR. The quality of obstetric care in family practice: Are family physicians as safe as obstetricians? J Fam Pract. 1987;24(2):159-164.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.