PCAP Services Description

Payments made pursuant to this AGREEMENT for ambulatory services to pregnant women shall be based upon a single payment schedule with a discrete price for each of the three clinic services set forth herein.

The three clinic services for which reimbursement shall be available according to the prices as established by the STATE are as follows:

  1. Initial Prenatal Evaluation - This visit shall be for women with confirmed determination of pregnancy for the purpose of initiating a prenatal care treatment regimen. Only one Initial Prenatal Evaluation may be billed per pregnancy. This visit shall include Medicaid presumptive eligibility determination; (completion of the Medicaid application process including the interview, assisting in the collection of documentation and forwarding the application package to the local social service district;) a complete history, physical examination and pelvic examination; risk assessment including medical and psychosocial factors; laboratory screening; lead screening; prenatal genetic risk screening; initiation of patient education; screening for nutritional status; and nutrition counseling and enrollment in the Supplemental Food and Nutrition Program for Women, Infants and Children (WIC). A standardized prenatal risk assessment-tool must be initiated at the first visit. The laboratory testing component of the risk assessment includes tests to determine the basic health status of the mother and the presence of health problems/concerns that may affect maternal and fetal health based on the recommendations of the American College of Obstetricians and Gynecologists. The New York State Department of Health recommended laboratory tests include, but are not limited to the following:
    • Hematocrit/Hemoglobin
    • Hemoglobin Electrophoresis or Chromatography, as indicated per sickle cell screening protocol
    • Blood group and RH determination
    • Irregular antibody screen
    • Rubella antibody titre
    • Syphilis test*
    • Gonorrhea screen
    • Cervical-vaginal cytology (PAP)
    • Chlamydia screen
    • Urinalysis
    • Hepatitis B surface antigen*

      *these tests are mandated by PHL §2308 (syphilis), PHL §2500, e (Hepatitis B)

      • Urine culture, as indicated
      • Tuberculin testing, as indicated
      • Obstetric ultrasound, as clinically indicated
      • Serum lead level, as indicated

      The following tests may not always be performed at the initial visit but should be offered to the client and scheduled with the client's consent at 15-18 weeks gestation:

      • Serum Alphafetoprotein (AFP)
      • Human Chorionic Gonadotropin (HCG)

      The above studies/testing can be done on-site or contracted through outside laboratories/agencies.

  2. Prenatal Followup Visits - These visits shall be for the purpose of providing ongoing prenatal care and shall include the following components:
    1. On-going risk assessment: review of symptoms such as headache, changes in vision, dizziness, edema, nausea and vomiting, bleeding, awareness of fetal movements, occurrence of contractions or rupture of membranes; review of laboratory data; and review of emerging medical and psychosocial factors with appropriate documentation in the care plan and referral when indicated. Each followup visit must include an encounter with a licensed prenatal provider (MD, licensed midwife, NP or PA).
    2. Physical Examination: Maternal blood pressure, weight, presence of edema, height of fundus, fetal position and heart beat.
    3. Recommended Laboratory Tests and Other Procedures:
      • urine testing for sugar and albumin at each visit
      • glucose challenge test at 28 weeks
      • Group B Streptococcus culture at 35-37 weeks, according to CDC guidelines
      • Rh titre, as indicated
      • repeat chlamydia, gonorrhea and syphilis screen during 3rd trimester, as clinically indicated.
      • repeat hematocrit or hemoglobin at 36 weeks
      • urinalysis and urine culture as clinically indicated
      • obstetric ultrasound as clinically indicated.

      Note: A non stress test (NST) and/or biophysical (BPP) profile performed on the same date of service as a prenatal follow-up visit, is part of the followup visit rate and may not be billed separately.

      If these tests are performed on a date of service other than a scheduled prenatal followup visit, the PCAP follow-up visit rate code may be billed only if all components of a prenatal follow-up visit are rendered.

    4. Health Education: A combination of private sessions with health personnel, group discussions or classes, and printed material in the client's native language.

      Health and childbirth education services are to be provided to each pregnant woman based on the needs identified in the initial and on-going risk assessments and documented in the medical record. The recommended health education program includes, but is not limited to, the following topics:

      • Orientation to facility procedures
      • Rights/responsibilities of the pregnant women
      • Signs of complications of pregnancy
      • Physical activity and exercise during pregnancy
      • Avoidance of harmful practices and substances including alcohol, drugs, non-prescribed medications, and nicotine
      • Sexuality during pregnancy
      • Occupational concerns
      • HIV education including the value of testing, the availability of medication for HIV positive women to reduce the risk of perinatal HIV transmission, the risks of HIV infection and risk reduction behaviors
      • Signs of labor
      • Labor and delivery process
      • Relaxation techniques in labor
      • Obstetrical anesthesia and analgesia
      • Preparation for parenting including infant development, care and options for feeding and orientation to expanded Medicaid eligibility for infants up to one year of age
      • The newborn screening program with the distribution of newborn screening educational literature
      • Family planning
  3. Postpartum Care - A postpartum visit shall be for the purpose of providing postpartum care for a period up to 60 days following delivery. Only one postpartum visit may be billed per pregnancy.

    A postpartum visit should occur between 4-8 weeks after delivery, depending upon the individual needs of the client and shall include the following components:

    1. On-going risk assessment: Review of medical, psychosocial, nutritional, alcohol treatment, drug treatment and educational needs of the mother, infant and family with appropriate referral when indicated.
    2. Physical examination: Assessment of the breasts, blood pressure, abdomen, external and internal genitalia and weight.
    3. Laboratory Studies: Hemogram and other tests, as indicated.
    4. Health Education: A combination of private sessions with health personnel, group discussions or classes, and printed material in the client's native language. Postpartum health education should be documented in the medical record and should include the following topics as indicated:
      • methods of family planning
      • pre-conceptional counseling needs
      • care of the infant, including infant feeding and pediatric follow-up
      • prevention of HIV and sexually transmitted diseases
      • physical activity and exercise
      • sexual activity
      • nutrition
      • infant development
      • expanded Medicaid eligibility for infants up to age one
    5. Family Planning: Assess family planning needs and provide advice and services or referral where indicated.

Prices established for the three clinic services provide full reimbursement for the following:

  1. physician services, nursing services, technician services, nutrition services, health education services, psychosocial services, care coordination services and other related professional expenses directly incurred by the licensed facility;
  2. space occupancy and plant overhead costs;
  3. administrative personnel, business office, data processing, recordkeeping, housekeeping, and other related facility overhead expenses;
  4. all ancillary services including laboratory tests and special procedures specified in the prenatal treatment regimen and/or as detailed in this AGREEMENT; and
  5. medical supplies, prenatal vitamins and iron supplements.

    PCAP rates do not include reimbursement for the following services which may be billed directly to Medicaid by the servicing provider. Detailed information regarding the proper billing of these services may be obtained by contacting the Bureau of Medical Review and Payment at 1-800-562-0856.

    • pharmaceuticals - all pharmaceuticals except vitamins and iron can be billed by the pharmacy to the Medicaid program.
    • HIV services including HIV pretest counseling, HIV testing and HIV posttest counseling under the following conditions:
      • If the Article 28 PCAP has signed the HIV Primary Care Provider Agreement, the agency can bill for HIV services on the same date of service as a PCAP encounter using the appropriate HIV rate codes. Otherwise, no separate reimbursement is allowed.
      • Private practicing obstetricians cannot bill HIV pre and posttest counseling fees unless they are enrolled in the HIV Enhanced Fees for Physicians Program (HIV-EFP) and identify an HIV positive woman and provide subsequent care for that HIV condition.
    • drug treatment and screening services
    • genetic services including ultrasonic guidance prior to amniocentesis, amniocentesis, chromosome analysis and physician/geneticist evaluation conditions.
    • mental health services
    • transportation services
    • inpatient care
    • specialty physician and clinic services
      • If client is referred off-site to a physician or nurse practitioner or specialty clinic for consultation or management of a particular condition, the PCAP is not responsible for reimbursement.
    • labor and delivery services
    • dental services
    • emergency room services
    • home care