Medical Coverage Policy

High Risk Pregnancy Services and Maternity Global Reimbursement

Device/Equipment Drug Medical Surgery Test Other

Effective Date: 9/1/2001 Policy Last Updated: 5/15/2012

Prospective review is recommended/required. Please check the member agreement for preauthorization guidelines.

Prospective review is not required.

Description: The services provided for an uncomplicated pregnancy include antepartum care, delivery, and postpartum care. The services provided for a high risk pregnancy are the same, but with medical or surgical problems complicating the antepartum period, including labor and delivery management. These pregnancies may require additional services and resources. The additional services and resources should be identified and documented in addition to the maternity care.

Antepartum care includes the initial and subsequent monthly visits for history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis. These monthly visits continue up to 28 weeks gestation; then biweekly visits to 36 weeks gestation; and finally, weekly visits again until delivery. The above services are included in the global maternity reimbursement and should not be reported separately. Any other visits or services within this time period may be reported and coded separately, if not related to routine maternity care.

Delivery services include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, and vaginal or cesarean delivery.

Postpartum care includes hospital and office visits following vaginal or cesarean section delivery. If a physician provides all or part of the antepartum and/or postpartum care, but does not perform the delivery, see the antepartum and postpartum care codes 59425-59426 and 59430.

Any evaluation and management (E&M) services performed that are related to the uncomplicated pregnancy are included in the provision of the antepartum care, and not reported separately. However, any other visits or services provided within the antepartum period, other than those listed above, may be coded and reported separately. The other services and resources that may be required for medical or surgical complications of pregnancy (e.g., cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, pre-term labor, premature rupture of membranes, appendectomy, hernia, ovarian cyst, Bartholin cyst) would require the additional, appropriate E&M, medical or surgical codes.1

Some of these services include, but are not limited to, the following:

· Management of inpatient or outpatient medical complications not related to pregnancy,

such as cardiac problems, neurologic problems, pneumonia, chronic hypertension, diabetes, etc.

· Management of inpatient or outpatient medical complications related to pregnancy, such as bleeding, preterm labor, pregnancy induced hypertension, toxemia, hyperemesis, premature rupture of membranes etc.

· The laboratory tests performed during pregnancy excluding dipstick urinalysis. · Management of surgical complications and problems of pregnancy, such as incompetent

cervix, hernia repair, ovarian cyst, Bartholin cyst, ruptured uterus, appendicitis. · Amniocentesis, chronic villous sampling, and cordocentesis (reported separately when

performed. · Fetal contraction stress test and fetal non stress test (reported separately when

performed. · Insertion of cervical dilator by physician (e.g., laminaria, prostaglandin. · External cephalic version with or without tocolysis. · The obstetric limited or complete ultrasound. · Fetal biophysical profile. · Fetal echocardiography.

Medical Criteria: None, as this is a reimbursement policy. Policy: Evaluation & Management (E&M) services in excess of the usual number (13) covered under the reimbursement for the global maternity codes, are eligible for separate reimbursement under the following conditions:

· The service is for the diagnosis, codes of which represent conditions which would qualify as high risk as listed below under High Risk Pregnancy Diagnosis Codes.

Description:

· The medical record accurately describes the services provided and billed; · The 13 E&M services covered by the Maternity Global Reimbursement have been exhausted.

E&M services identified as high risk maternity service office visits are those in excess of the usual number covered under the reimbursement for the global maternity benefit, and will not be subject to member office visit copayment. E&M services unrelated to office visits for maternity care would follow the standard office copayment benefit. Coverage: Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for the applicable "Pregnancy Services and Nursery Care" and Office Visit benefits/coverage. Coding: The following are diagnosis codes which may lead to a pregnancy being labeled high risk: High Risk Pregnancy Diagnosis Codes: ICD-9 ICD-10

640.00 O20.0 640.03 O20.0 640.80 O20.8 640.83 O20.8 640.90 O20.9 640.93 O20.9 641.00 O44.00 641.03 O44.01 641.03 O44.02 641.03 O44.03 641.10 O44.10 641.13 O44.11 641.13 O44.12 641.13 O44.13 641.20 O45.8x9 641.20 O45.90 641.23 O45.8x1 641.23 O45.8x2 641.23 O45.8x3 641.23 O45.91 641.23 O45.92 641.23 O45.93 641.30 O45.009 641.30 O45.019 641.30 O45.029 641.30 O45.099 641.30 O46.009 641.30 O46.019 641.30 O46.029 641.30 O46.099 641.33 O45.001 641.33 O45.002 641.33 O45.003 641.33 O45.011 641.33 O45.012 641.33 O45.013 641.33 O45.021 641.33 O45.022 641.33 O45.023 641.33 O45.091 641.33 O45.092 641.33 O45.093 641.33 O46.001 641.33 O46.002 641.33 O46.003 641.33 O46.011 641.33 O46.012 641.33 O46.013 641.33 O46.021 641.33 O46.022 641.33 O46.023

641.33 O46.091 641.33 O46.092 641.33 O46.093 641.80 O46.8x9 641.83 O46.8x1 641.83 O46.8x2 641.83 O46.8x3 641.90 O46.90 641.93 O46.91 641.93 O46.92 641.93 O46.93 642.00 O10.019 642.00 O10.919 642.01 O10.011 642.01 O10.012 642.01 O10.013 642.01 O10.02 642.01 O10.911 642.01 O10.912 642.01 O10.913 642.01 O10.92 642.02 O10.03 642.03 O10.011 642.03 O10.012 642.03 O10.013 642.03 O10.911 642.03 O10.912 642.03 O10.913 642.04 O10.03 642.04 O10.93 642.10 O10.419 642.11 O10.411 642.11 O10.412 642.11 O10.413 642.11 O10.42 642.12 O10.43 642.13 O10.411 642.13 O10.412 642.13 O10.413 642.14 O10.43 642.20 O10.119 642.20 O10.219 642.20 O10.319 642.20 O11.9 642.21 O10.111 642.21 O10.112 642.21 O10.113 642.21 O10.12 642.21 O10.211 642.21 O10.212 642.21 O10.213

642.21 O10.22 642.21 O10.311 642.21 O10.312 642.21 O10.313 642.21 O10.32 642.21 O11.1 642.21 O11.2 642.21 O11.3 642.22 O10.13 642.23 O10.111 642.23 O10.112 642.23 O10.113 642.23 O10.211 642.23 O10.212 642.23 O10.213 642.23 O10.311 642.23 O10.312 642.23 O10.313 642.23 O11.1 642.23 O11.2 642.23 O11.3 642.24 O10.13 642.24 O10.23 642.24 O10.33 642.30 O13.9 642.31 O13.1 642.31 O13.2 642.31 O13.3 642.31 O16.1 642.31 O16.2 642.31 O16.3 642.32 O13.1 642.32 O13.2 642.32 O13.3 642.33 O13.1 642.33 O13.2 642.33 O13.3 642.33 O16.1 642.33 O16.2 642.33 O16.3 642.34 O13.1 642.34 O13.2 642.34 O13.3 642.40 O14.00 642.40 O14.90 642.41 O14.02 642.41 O14.03 642.41 O14.92 642.41 O14.93 642.42 O14.02 642.42 O14.03

642.43 O14.02 642.43 O14.03 642.43 O14.92 642.43 O14.93 642.44 O15.2 642.50 O14.10 642.50 O14.20 642.51 O14.12 642.51 O14.13 642.51 O14.22 642.51 O14.23 642.52 O14.12 642.52 O14.13 642.52 O14.22 642.52 O14.23 642.53 O14.12 642.53 O14.13 642.53 O14.22 642.53 O14.23 642.54 O14.12 642.54 O14.13 642.54 O14.22 642.54 O14.23 642.60 O15.00 642.60 O15.9 642.61 O15.02 642.61 O15.03 642.61 O15.1 642.62 O15.2 642.63 O15.02 642.63 O15.03 642.64 O15.2 642.70 O11.9 642.71 O11.1 642.71 O11.2 642.71 O11.3 642.72 O15.2 642.73 O11.1 642.73 O11.2 642.73 O11.3 642.74 O15.2 642.90 O16.9 642.91 O10.92 642.91 O16.1 642.91 O16.2 642.91 O16.3 642.92 O16.9 642.93 O16.1 642.93 O16.2 642.93 O16.3 642.94 O10.93

642.94 O16.1 642.94 O16.2 642.94 O16.3 643.00 O21.0 643.03 O21.0 643.10 O21.1 643.13 O21.1 643.20 O21.2 643.23 O21.2 643.80 O21.8 643.83 O21.8 643.90 O21.9 643.93 O21.9 644.00 O60.00 644.03 O60.02 644.03 O60.03 644.10 O47.00 644.10 O47.9 644.13 O47.02 644.13 O47.03 644.13 O47.1 644.20 O60.10x0 644.20 O60.10x1 644.20 O60.10x2 644.20 O60.10x3 644.20 O60.10x4 644.20 O60.10x5 644.20 O60.10x9 644.20 O60.20x0 644.20 O60.20x1 644.20 O60.20x2 644.20 O60.20x3 644.20 O60.20x4 644.20 O60.20x5 644.20 O60.20x9 645.10 O48.0 645.13 O48.0 645.20 O48.1 645.23 O48.1 646.00 O31.00x0 646.00 O31.00x1 646.00 O31.00x2 646.00 O31.00x3 646.00 O31.00x4 646.00 O31.00x5 646.00 O31.00x9 646.03 O31.01x0 646.03 O31.01x1 646.03 O31.01x2 646.03 O31.01x3 646.03 O31.01x4

646.03 O31.01x5 646.03 O31.01x9 646.03 O31.02x0 646.03 O31.02x1 646.03 O31.02x2 646.03 O31.02x3 646.03 O31.02x4 646.03 O31.02x5 646.03 O31.02x9 646.03 O31.03x0 646.03 O31.03x1 646.03 O31.03x2 646.03 O31.03x3 646.03 O31.03x4 646.03 O31.03x5 646.03 O31.03x9 646.10 O12.00 646.10 O12.20 646.10 O26.00 646.13 O12.01 646.13 O12.02 646.13 O12.03 646.13 O12.21 646.13 O12.22 646.13 O12.23 646.13 O26.01 646.13 O26.02 646.13 O26.03 646.20 O12.10 646.20 O12.20 646.20 O26.839 646.23 O12.11 646.23 O12.12 646.23 O12.13 646.23 O12.21 646.23 O12.22 646.23 O12.23 646.23 O26.831 646.23 O26.832 646.23 O26.833 646.30 O26.20 646.33 O26.21 646.33 O26.22 646.33 O26.23 646.40 O26.829 646.43 O26.821 646.43 O26.822 646.43 O26.823 646.50 O23.00 646.50 O23.10 646.50 O23.20

646.50 O23.30 646.50 O23.40 646.50 O23.519 646.50 O23.529 646.50 O23.599 646.50 O23.90 646.53 O23.41 646.53 O23.42 646.53 O23.43 646.60 O23.00 646.60 O23.10 646.60 O23.20 646.60 O23.30 646.60 O23.40 646.60 O23.519 646.60 O23.529 646.60 O23.599 646.60 O23.90 646.63 O23.01 646.63 O23.02 646.63 O23.03 646.63 O23.11 646.63 O23.12 646.63 O23.13 646.63 O23.21 646.63 O23.22 646.63 O23.23 646.63 O23.31 646.63 O23.32 646.63 O23.33 646.63 O23.41 646.63 O23.42 646.63 O23.43 646.63 O23.511 646.63 O23.512 646.63 O23.513 646.63 O23.521 646.63 O23.522 646.63 O23.523 646.63 O23.591 646.63 O23.592 646.63 O23.593 646.63 O23.91 646.63 O23.92 646.63 O23.93 646.70 O26.619 646.73 O26.611 646.73 O26.612 646.73 O26.613 646.80 O26.10 646.80 O26.30

646.80 O26.40 646.80 O26.719 646.80 O26.819 646.80 O26.899 646.80 O29.019 646.80 O29.029 646.80 O29.099 646.80 O29.119 646.80 O29.129 646.80 O29.199 646.80 O29.219 646.80 O29.299 646.80 O29.3x9 646.80 O29.40 646.80 O29.5x9 646.80 O29.60 646.80 O29.8x9 646.80 O29.90 646.80 O99.350 646.80 O99.89 646.83 O26.11 646.83 O26.12 646.83 O26.13 646.83 O26.31 646.83 O26.32 646.83 O26.33 646.83 O26.41 646.83 O26.42 646.83 O26.43 646.83 O26.711 646.83 O26.712 646.83 O26.713 646.83 O26.811 646.83 O26.812 646.83 O26.813 646.83 O26.86 646.83 O26.891 646.83 O26.892 646.83 O26.893 646.83 O26.91 646.83 O26.92 646.83 O26.93 646.83 O29.011 646.83 O29.012 646.83 O29.013 646.83 O29.021 646.83 O29.022 646.83 O29.023 646.83 O29.091 646.83 O29.092 646.83 O29.093

646.83 O29.111 646.83 O29.112 646.83 O29.113 646.83 O29.121 646.83 O29.122 646.83 O29.123 646.83 O29.191 646.83 O29.192 646.83 O29.193 646.83 O29.211 646.83 O29.212 646.83 O29.213 646.83 O29.291 646.83 O29.292 646.83 O29.293 646.83 O29.3x1 646.83 O29.3x2 646.83 O29.3x3 646.83 O29.41 646.83 O29.42 646.83 O29.43 646.83 O29.5x1 646.83 O29.5x2 646.83 O29.5x3 646.83 O29.61 646.83 O29.62 646.83 O29.63 646.83 O29.8x1 646.83 O29.8x2 646.83 O29.8x3 646.83 O29.91 646.83 O29.92 646.83 O29.93 646.83 O99.351 646.83 O99.352 646.83 O99.353 646.83 O99.89 646.90 O26.90 646.93 O99.89 647.00 O98.119 647.03 O98.111 647.03 O98.112 647.03 O98.113 647.10 O98.219 647.13 O98.211 647.13 O98.212 647.13 O98.213 647.20 O98.319 647.23 O98.311 647.23 O98.312 647.23 O98.313

647.30 O98.019 647.33 O98.011 647.33 O98.012 647.33 O98.013 647.40 O98.619 647.43 O98.611 647.43 O98.612 647.43 O98.613 647.50 O98.519 647.53 O98.511 647.53 O98.512 647.53 O98.513 647.60 O98.419 647.60 O98.519 647.60 O98.719 647.63 O98.411 647.63 O98.412 647.63 O98.413 647.63 O98.511 647.63 O98.512 647.63 O98.513 647.63 O98.711 647.63 O98.712 647.63 O98.713 647.80 O98.719 647.80 O98.819 647.83 O98.611 647.83 O98.612 647.83 O98.613 647.83 O98.711 647.83 O98.712 647.83 O98.713 647.83 O98.811 647.83 O98.812 647.83 O98.813 647.83 O99.830 647.90 O98.919 647.93 O98.911 647.93 O98.912 647.93 O98.913 648.00 O24.019 648.00 O24.119 648.00 O24.319 648.00 O24.819 648.00 O24.919 648.03 O24.011 648.03 O24.012 648.03 O24.013 648.03 O24.111 648.03 O24.112 648.03 O24.113

648.03 O24.311 648.03 O24.312 648.03 O24.313 648.03 O24.811 648.03 O24.812 648.03 O24.813 648.03 O24.911 648.03 O24.912 648.03 O24.913 648.10 O99.280 648.13 O99.281 648.13 O99.282 648.13 O99.283 648.20 O99.019 648.23 O99.011 648.23 O99.012 648.23 O99.013 648.30 O99.320 648.33 O99.321 648.33 O99.322 648.33 O99.323 648.40 O99.310 648.40 O99.340 648.43 O99.311 648.43 O99.312 648.43 O99.313 648.43 O99.341 648.43 O99.342 648.43 O99.343 648.50 O99.419 648.53 O99.411 648.53 O99.412 648.53 O99.413 648.60 O99.419 648.63 O99.411 648.63 O99.412 648.63 O99.413 648.70 O33.0 648.73 O33.0 648.80 O99.810 648.83 O24.410 648.83 O24.414 648.83 O24.419 648.83 O99.810 648.90 O25.10 648.90 O99.280 648.90 O99.519 648.90 O99.619 648.90 O99.719 648.90 O9A.119 648.90 O9A.219

648.90 O9A.319 648.90 O9A.419 648.90 O9A.519 648.93 O25.11 648.93 O25.12 648.93 O25.13 648.93 O99.281 648.93 O99.282 648.93 O99.283 648.93 O99.511 648.93 O99.512 648.93 O99.513 648.93 O99.611 648.93 O99.612 648.93 O99.613 648.93 O99.711 648.93 O99.712 648.93 O99.713 648.93 O99.820 648.93 O9A.111 648.93 O9A.112 648.93 O9A.113 648.93 O9A.211 648.93 O9A.212 648.93 O9A.213 648.93 O9A.311 648.93 O9A.312 648.93 O9A.313 648.93 O9A.411 648.93 O9A.412 648.93 O9A.413 648.93 O9A.511 648.93 O9A.512 648.93 O9A.513 649.00 O99.330 649.03 O99.331 649.03 O99.332 649.03 O99.333 649.10 O99.210 649.13 O99.211 649.13 O99.212 649.13 O99.213 649.20 O99.840 649.23 O99.841 649.23 O99.842 649.23 O99.843 649.30 O99.119 649.33 O99.111 649.33 O99.112 649.33 O99.113 649.40 O99.350

649.43 O99.351 649.43 O99.352 649.43 O99.353 649.50 O26.859 649.53 O26.851 649.53 O26.852 649.53 O26.853 649.60 O26.849 649.63 O26.841 649.63 O26.842 649.63 O26.843 649.81 O75.82 649.82 O75.82 651.00 O30.009 651.00 O30.019 651.00 O30.039 651.00 O30.049 651.00 O30.099 651.03 O30.001 651.03 O30.002 651.03 O30.003 651.03 O30.011 651.03 O30.012 651.03 O30.013 651.03 O30.031 651.03 O30.032 651.03 O30.033 651.03 O30.041 651.03 O30.042 651.03 O30.043 651.03 O30.091 651.03 O30.092 651.03 O30.093 651.10 O30.109 651.10 O30.119 651.10 O30.129 651.10 O30.199 651.13 O30.101 651.13 O30.102 651.13 O30.103 651.13 O30.111 651.13 O30.112 651.13 O30.113 651.13 O30.121 651.13 O30.122 651.13 O30.123 651.13 O30.191 651.13 O30.192 651.13 O30.193 651.20 O30.209 651.20 O30.219

651.20 O30.229 651.20 O30.299 651.23 O30.201 651.23 O30.202 651.23 O30.203 651.23 O30.211 651.23 O30.212 651.23 O30.213 651.23 O30.221 651.23 O30.222 651.23 O30.223 651.23 O30.291 651.23 O30.292 651.23 O30.293 651.30 O31.10x0 651.30 O31.10x1 651.30 O31.10x2 651.30 O31.10x3 651.30 O31.10x4 651.30 O31.10x5 651.30 O31.10x9 651.30 O31.20x0 651.30 O31.20x1 651.30 O31.20x2 651.30 O31.20x3 651.30 O31.20x4 651.30 O31.20x5 651.30 O31.20x9 651.33 O31.11x0 651.33 O31.11x1 651.33 O31.11x2 651.33 O31.11x3 651.33 O31.11x4 651.33 O31.11x5 651.33 O31.11x9 651.33 O31.12x0 651.33 O31.12x1 651.33 O31.12x2 651.33 O31.12x3 651.33 O31.12x4 651.33 O31.12x5 651.33 O31.12x9 651.33 O31.13x0 651.33 O31.13x1 651.33 O31.13x2 651.33 O31.13x3 651.33 O31.13x4 651.33 O31.13x5 651.33 O31.13x9 651.33 O31.21x0 651.33 O31.21x1

651.33 O31.21x2 651.33 O31.21x3 651.33 O31.21x4 651.33 O31.21x5 651.33 O31.21x9 651.33 O31.22x0 651.33 O31.22x1 651.33 O31.22x2 651.33 O31.22x3 651.33 O31.22x4 651.33 O31.22x5 651.33 O31.22x9 651.33 O31.23x0 651.33 O31.23x1 651.33 O31.23x2 651.33 O31.23x3 651.33 O31.23x4 651.33 O31.23x5 651.33 O31.23x9 651.40 O31.10x0 651.43 O31.11x0 651.50 O31.10x0 651.53 O31.11x0 651.60 O31.10x0 651.60 O31.10x1 651.60 O31.10x2 651.60 O31.10x3 651.60 O31.10x4 651.60 O31.10x5 651.60 O31.10x9 651.60 O31.20x0 651.60 O31.20x1 651.60 O31.20x2 651.60 O31.20x3 651.60 O31.20x4 651.60 O31.20x5 651.60 O31.20x9 651.63 O31.11x0 651.63 O31.11x1 651.63 O31.11x2 651.63 O31.11x3 651.63 O31.11x4 651.63 O31.11x5 651.63 O31.11x9 651.63 O31.12x0 651.63 O31.12x1 651.63 O31.12x2 651.63 O31.12x3 651.63 O31.12x4 651.63 O31.12x5 651.63 O31.12x9

651.63 O31.13x0 651.63 O31.13x1 651.63 O31.13x2 651.63 O31.13x3 651.63 O31.13x4 651.63 O31.13x5 651.63 O31.13x9 651.63 O31.21x0 651.63 O31.21x1 651.63 O31.21x2 651.63 O31.21x3 651.63 O31.21x4 651.63 O31.21x5 651.63 O31.21x9 651.63 O31.22x0 651.63 O31.22x1 651.63 O31.22x2 651.63 O31.22x3 651.63 O31.22x4 651.63 O31.22x5 651.63 O31.22x9 651.63 O31.23x0 651.63 O31.23x1 651.63 O31.23x2 651.63 O31.23x3 651.63 O31.23x4 651.63 O31.23x5 651.63 O31.23x9 651.70 O31.30x0 651.70 O31.30x1 651.70 O31.30x2 651.70 O31.30x3 651.70 O31.30x4 651.70 O31.30x5 651.70 O31.30x9 651.73 O31.31x0 651.73 O31.31x1 651.73 O31.31x2 651.73 O31.31x3 651.73 O31.31x4 651.73 O31.31x5 651.73 O31.31x9 651.73 O31.32x0 651.73 O31.32x1 651.73 O31.32x2 651.73 O31.32x3 651.73 O31.32x4 651.73 O31.32x5 651.73 O31.32x9 651.73 O31.33x0 651.73 O31.33x1

651.73 O31.33x2 651.73 O31.33x3 651.73 O31.33x4 651.73 O31.33x5 651.73 O31.33x9 651.80 O30.809 651.80 O30.819 651.80 O30.829 651.80 O30.899 651.83 O30.801 651.83 O30.802 651.83 O30.803 651.83 O30.811 651.83 O30.812 651.83 O30.813 651.83 O30.821 651.83 O30.822 651.83 O30.823 651.83 O30.891 651.83 O30.892 651.83 O30.893 651.83 O31.8x10 651.83 O31.8x11 651.83 O31.8x12 651.83 O31.8x13 651.83 O31.8x14 651.83 O31.8x15 651.83 O31.8x19 651.83 O31.8x20 651.83 O31.8x21 651.83 O31.8x22 651.83 O31.8x23 651.83 O31.8x24 651.83 O31.8x25 651.83 O31.8x29 651.83 O31.8x30 651.83 O31.8x31 651.83 O31.8x32 651.83 O31.8x33 651.83 O31.8x34 651.83 O31.8x35 651.83 O31.8x39 651.90 O30.90 651.90 O31.8x90 651.90 O31.8x91 651.90 O31.8x92 651.90 O31.8x93 651.90 O31.8x94 651.90 O31.8x95 651.90 O31.8x99 651.93 O30.91

651.93 O30.92 651.93 O30.93 652.00 O32.0xx0 652.03 O32.0xx0 652.03 O32.0xx1 652.03 O32.0xx2 652.03 O32.0xx3 652.03 O32.0xx4 652.03 O32.0xx5 652.03 O32.0xx9 652.10 O32.1xx0 652.13 O32.1xx0 652.20 O32.1xx0 652.30 O32.2xx0 652.33 O32.2xx0 652.33 O32.2xx1 652.33 O32.2xx2 652.33 O32.2xx3 652.33 O32.2xx4 652.33 O32.2xx5 652.33 O32.2xx9 652.40 O32.3xx0 652.43 O32.3xx0 652.43 O32.3xx1 652.43 O32.3xx2 652.43 O32.3xx3 652.43 O32.3xx4 652.43 O32.3xx5 652.43 O32.3xx9 652.50 O32.4xx0 652.53 O32.4xx0 652.53 O32.4xx1 652.53 O32.4xx2 652.53 O32.4xx3 652.53 O32.4xx4 652.53 O32.4xx5 652.53 O32.4xx9 652.60 O32.9xx0 652.63 O32.9xx0 652.70 O32.8xx0 652.73 O32.8xx0 652.80 O32.8xx0 652.83 O32.6xx0 652.83 O32.6xx1 652.83 O32.6xx2 652.83 O32.6xx3 652.83 O32.6xx4 652.83 O32.6xx5 652.83 O32.6xx9 652.83 O32.8xx0 652.83 O32.8xx1

652.83 O32.8xx2 652.83 O32.8xx3 652.83 O32.8xx4 652.83 O32.8xx5 652.83 O32.8xx9 652.90 O32.9xx0 652.93 O32.9xx0 652.93 O32.9xx1 652.93 O32.9xx2 652.93 O32.9xx3 652.93 O32.9xx4 652.93 O32.9xx5 652.93 O32.9xx9 653.00 O33.0 653.03 O33.0 653.10 O33.1 653.13 O33.1 653.20 O33.2 653.23 O33.2 653.30 O33.3xx0 653.33 O33.3xx0 653.33 O33.3xx1 653.33 O33.3xx2 653.33 O33.3xx3 653.33 O33.3xx4 653.33 O33.3xx5 653.33 O33.3xx9 653.40 O33.4xx0 653.43 O33.4xx0 653.43 O33.4xx1 653.43 O33.4xx2 653.43 O33.4xx3 653.43 O33.4xx4 653.43 O33.4xx5 653.43 O33.4xx9 653.50 O33.5xx0 653.53 O33.5xx0 653.53 O33.5xx1 653.53 O33.5xx2 653.53 O33.5xx3 653.53 O33.5xx4 653.53 O33.5xx5 653.53 O33.5xx9 653.60 O33.6xx0 653.63 O33.6xx0 653.63 O33.6xx1 653.63 O33.6xx2 653.63 O33.6xx3 653.63 O33.6xx4 653.63 O33.6xx5 653.63 O33.6xx9

653.70 O33.7 653.73 O33.7 653.80 O33.8 653.83 O33.8 653.90 O33.9 653.93 O33.9 654.00 O34.00 654.03 O34.01 654.03 O34.02 654.03 O34.03 654.10 O34.10 654.13 O34.11 654.13 O34.12 654.13 O34.13 654.20 O34.21 654.23 O34.21 654.30 O34.519 654.30 O34.539 654.33 O34.511 654.33 O34.512 654.33 O34.513 654.33 O34.531 654.33 O34.532 654.33 O34.533 654.40 O34.529 654.40 O34.599 654.43 O34.521 654.43 O34.522 654.43 O34.523 654.43 O34.591 654.43 O34.592 654.43 O34.593 654.50 O34.30 654.53 O34.31 654.53 O34.32 654.53 O34.33 654.60 O34.40 654.63 O34.41 654.63 O34.42 654.63 O34.43 654.70 O34.60 654.73 O34.61 654.73 O34.62 654.73 O34.63 654.80 O34.70 654.83 O34.71 654.83 O34.72 654.83 O34.73 654.90 O34.80 654.90 O34.90 654.93 O34.29

654.93 O34.81 654.93 O34.82 654.93 O34.83 654.93 O34.91 654.93 O34.92 654.93 O34.93 655.00 O35.0xx0 655.03 O35.0xx0 655.03 O35.0xx1 655.03 O35.0xx2 655.03 O35.0xx3 655.03 O35.0xx4 655.03 O35.0xx5 655.03 O35.0xx9 655.10 O35.1xx0 655.13 O35.1xx0 655.13 O35.1xx1 655.13 O35.1xx2 655.13 O35.1xx3 655.13 O35.1xx4 655.13 O35.1xx5 655.13 O35.1xx9 655.20 O35.2xx0 655.23 O35.2xx0 655.23 O35.2xx1 655.23 O35.2xx2 655.23 O35.2xx3 655.23 O35.2xx4 655.23 O35.2xx5 655.23 O35.2xx9 655.30 O35.3xx0 655.33 O35.3xx0 655.33 O35.3xx1 655.33 O35.3xx2 655.33 O35.3xx3 655.33 O35.3xx4 655.33 O35.3xx5 655.33 O35.3xx9 655.40 O35.4xx0 655.43 O35.4xx0 655.43 O35.4xx1 655.43 O35.4xx2 655.43 O35.4xx3 655.43 O35.4xx4 655.43 O35.4xx5 655.43 O35.4xx9 655.50 O35.5xx0 655.53 O35.5xx0 655.53 O35.5xx1 655.53 O35.5xx2 655.53 O35.5xx3

655.53 O35.5xx4 655.53 O35.5xx5 655.53 O35.5xx9 655.60 O35.6xx0 655.63 O35.6xx0 655.63 O35.6xx1 655.63 O35.6xx2 655.63 O35.6xx3 655.63 O35.6xx4 655.63 O35.6xx5 655.63 O35.6xx9 655.70 O36.8190 655.73 O36.8120 655.73 O36.8121 655.73 O36.8122 655.73 O36.8123 655.73 O36.8124 655.73 O36.8125 655.73 O36.8129 655.73 O36.8130 655.73 O36.8131 655.73 O36.8132 655.73 O36.8133 655.73 O36.8134 655.73 O36.8135 655.73 O36.8139 655.73 O36.8190 655.73 O36.8191 655.73 O36.8192 655.73 O36.8193 655.73 O36.8194 655.73 O36.8195 655.73 O36.8199 655.80 O35.8xx0 655.83 O35.8xx0 655.83 O35.8xx1 655.83 O35.8xx2 655.83 O35.8xx3 655.83 O35.8xx4 655.83 O35.8xx5 655.83 O35.8xx9 655.90 O35.9xx0 655.93 O35.9xx0 655.93 O35.9xx1 655.93 O35.9xx2 655.93 O35.9xx3 655.93 O35.9xx4 655.93 O35.9xx5 655.93 O35.9xx9 656.00 O43.019 656.00 O43.029

656.03 O43.011 656.03 O43.012 656.03 O43.013 656.03 O43.021 656.03 O43.022 656.03 O43.023 656.10 O36.0190 656.10 O36.0191 656.10 O36.0192 656.10 O36.0193 656.10 O36.0194 656.10 O36.0195 656.10 O36.0199 656.10 O36.0990 656.10 O36.0991 656.10 O36.0992 656.10 O36.0993 656.10 O36.0994 656.10 O36.0995 656.10 O36.0999 656.13 O36.0110 656.13 O36.0111 656.13 O36.0112 656.13 O36.0113 656.13 O36.0114 656.13 O36.0115 656.13 O36.0119 656.13 O36.0120 656.13 O36.0121 656.13 O36.0122 656.13 O36.0123 656.13 O36.0124 656.13 O36.0125 656.13 O36.0129 656.13 O36.0130 656.13 O36.0131 656.13 O36.0132 656.13 O36.0133 656.13 O36.0134 656.13 O36.0135 656.13 O36.0139 656.13 O36.0910 656.13 O36.0911 656.13 O36.0912 656.13 O36.0913 656.13 O36.0914 656.13 O36.0915 656.13 O36.0919 656.13 O36.0920 656.13 O36.0921 656.13 O36.0922

656.13 O36.0923 656.13 O36.0924 656.13 O36.0925 656.13 O36.0929 656.13 O36.0930 656.13 O36.0931 656.13 O36.0932 656.13 O36.0933 656.13 O36.0934 656.13 O36.0935 656.13 O36.0939 656.20 O36.1190 656.20 O36.1191 656.20 O36.1192 656.20 O36.1193 656.20 O36.1194 656.20 O36.1195 656.20 O36.1199 656.20 O36.1990 656.20 O36.1991 656.20 O36.1992 656.20 O36.1993 656.20 O36.1994 656.20 O36.1995 656.20 O36.1999 656.23 O36.1110 656.23 O36.1111 656.23 O36.1112 656.23 O36.1113 656.23 O36.1114 656.23 O36.1115 656.23 O36.1119 656.23 O36.1120 656.23 O36.1121 656.23 O36.1122 656.23 O36.1123 656.23 O36.1124 656.23 O36.1125 656.23 O36.1129 656.23 O36.1130 656.23 O36.1131 656.23 O36.1132 656.23 O36.1133 656.23 O36.1134 656.23 O36.1135 656.23 O36.1139 656.23 O36.1910 656.23 O36.1911 656.23 O36.1912 656.23 O36.1913 656.23 O36.1914

656.23 O36.1915 656.23 O36.1919 656.23 O36.1920 656.23 O36.1921 656.23 O36.1922 656.23 O36.1923 656.23 O36.1924 656.23 O36.1925 656.23 O36.1929 656.23 O36.1930 656.23 O36.1931 656.23 O36.1932 656.23 O36.1933 656.23 O36.1934 656.23 O36.1935 656.23 O36.1939 656.30 O68 656.33 O68 656.40 O36.4xx0 656.43 O36.4xx0 656.43 O36.4xx1 656.43 O36.4xx2 656.43 O36.4xx3 656.43 O36.4xx4 656.43 O36.4xx5 656.43 O36.4xx9 656.50 O36.5190 656.50 O36.5191 656.50 O36.5192 656.50 O36.5193 656.50 O36.5194 656.50 O36.5195 656.50 O36.5199 656.50 O36.5990 656.50 O36.5991 656.50 O36.5992 656.50 O36.5993 656.50 O36.5994 656.50 O36.5995 656.50 O36.5999 656.53 O36.5110 656.53 O36.5111 656.53 O36.5112 656.53 O36.5113 656.53 O36.5114 656.53 O36.5115 656.53 O36.5119 656.53 O36.5120 656.53 O36.5121 656.53 O36.5122 656.53 O36.5123

656.53 O36.5124 656.53 O36.5125 656.53 O36.5129 656.53 O36.5130 656.53 O36.5131 656.53 O36.5132 656.53 O36.5133 656.53 O36.5134 656.53 O36.5135 656.53 O36.5139 656.53 O36.5910 656.53 O36.5911 656.53 O36.5912 656.53 O36.5913 656.53 O36.5914 656.53 O36.5915 656.53 O36.5919 656.53 O36.5920 656.53 O36.5921 656.53 O36.5922 656.53 O36.5923 656.53 O36.5924 656.53 O36.5925 656.53 O36.5929 656.53 O36.5930 656.53 O36.5931 656.53 O36.5932 656.53 O36.5933 656.53 O36.5934 656.53 O36.5935 656.53 O36.5939 656.60 O36.60x0 656.60 O36.60x1 656.60 O36.60x2 656.60 O36.60x3 656.60 O36.60x4 656.60 O36.60x5 656.60 O36.60x9 656.63 O36.61x0 656.63 O36.61x1 656.63 O36.61x2 656.63 O36.61x3 656.63 O36.61x4 656.63 O36.61x5 656.63 O36.61x9 656.63 O36.62x0 656.63 O36.62x1 656.63 O36.62x2 656.63 O36.62x3 656.63 O36.62x4 656.63 O36.62x5

656.63 O36.62x9 656.63 O36.63x0 656.63 O36.63x1 656.63 O36.63x2 656.63 O36.63x3 656.63 O36.63x4 656.63 O36.63x5 656.63 O36.63x9 656.70 O43.109 656.70 O43.119 656.70 O43.199 656.70 O43.819 656.70 O43.90 656.73 O43.101 656.73 O43.102 656.73 O43.103 656.73 O43.111 656.73 O43.112 656.73 O43.113 656.73 O43.191 656.73 O43.192 656.73 O43.193 656.73 O43.811 656.73 O43.812 656.73 O43.813 656.73 O43.91 656.73 O43.92 656.73 O43.93 656.80 O36.20x0 656.80 O36.20x1 656.80 O36.20x2 656.80 O36.20x3 656.80 O36.20x4 656.80 O36.20x5 656.80 O36.20x9 656.80 O36.70x0 656.80 O36.70x1 656.80 O36.70x2 656.80 O36.70x3 656.80 O36.70x4 656.80 O36.70x5 656.80 O36.70x9 656.80 O36.8990 656.80 O36.8991 656.80 O36.8992 656.80 O36.8993 656.80 O36.8994 656.80 O36.8995 656.80 O36.8999 656.80 O43.899 656.80 O68

656.80 O77.0 656.83 O36.21x0 656.83 O36.21x1 656.83 O36.21x2 656.83 O36.21x3 656.83 O36.21x4 656.83 O36.21x5 656.83 O36.21x9 656.83 O36.22x0 656.83 O36.22x1 656.83 O36.22x2 656.83 O36.22x3 656.83 O36.22x4 656.83 O36.22x5 656.83 O36.22x9 656.83 O36.23x0 656.83 O36.23x1 656.83 O36.23x2 656.83 O36.23x3 656.83 O36.23x4 656.83 O36.23x5 656.83 O36.23x9 656.83 O36.71x0 656.83 O36.71x1 656.83 O36.71x2 656.83 O36.71x3 656.83 O36.71x4 656.83 O36.71x5 656.83 O36.71x9 656.83 O36.72x0 656.83 O36.72x1 656.83 O36.72x2 656.83 O36.72x3 656.83 O36.72x4 656.83 O36.72x5 656.83 O36.72x9 656.83 O36.73x0 656.83 O36.73x1 656.83 O36.73x2 656.83 O36.73x3 656.83 O36.73x4 656.83 O36.73x5 656.83 O36.73x9 656.83 O36.8910 656.83 O36.8911 656.83 O36.8912 656.83 O36.8913 656.83 O36.8914 656.83 O36.8915 656.83 O36.8919 656.83 O36.8920

656.83 O36.8921 656.83 O36.8922 656.83 O36.8923 656.83 O36.8924 656.83 O36.8925 656.83 O36.8929 656.83 O36.8930 656.83 O36.8931 656.83 O36.8932 656.83 O36.8933 656.83 O36.8934 656.83 O36.8935 656.83 O36.8939 656.83 O43.891 656.83 O43.892 656.83 O43.893 656.83 O68 656.90 O36.90x0 656.90 O36.90x1 656.90 O36.90x2 656.90 O36.90x3 656.90 O36.90x4 656.90 O36.90x5 656.90 O36.90x9 656.93 O36.91x0 656.93 O36.91x1 656.93 O36.91x2 656.93 O36.91x3 656.93 O36.91x4 656.93 O36.91x5 656.93 O36.91x9 656.93 O36.92x0 656.93 O36.92x1 656.93 O36.92x2 656.93 O36.92x3 656.93 O36.92x4 656.93 O36.92x5 656.93 O36.92x9 656.93 O36.93x0 656.93 O36.93x1 656.93 O36.93x2 656.93 O36.93x3 656.93 O36.93x4 656.93 O36.93x5 656.93 O36.93x9 657.00 O40.9xx0 657.00 O40.9xx1 657.00 O40.9xx2 657.00 O40.9xx3 657.00 O40.9xx4 657.00 O40.9xx5

657.00 O40.9xx9 657.03 O40.1xx0 657.03 O40.1xx1 657.03 O40.1xx2 657.03 O40.1xx3 657.03 O40.1xx4 657.03 O40.1xx5 657.03 O40.1xx9 657.03 O40.2xx0 657.03 O40.2xx1 657.03 O40.2xx2 657.03 O40.2xx3 657.03 O40.2xx4 657.03 O40.2xx5 657.03 O40.2xx9 657.03 O40.3xx0 657.03 O40.3xx1 657.03 O40.3xx2 657.03 O40.3xx3 657.03 O40.3xx4 657.03 O40.3xx5 657.03 O40.3xx9 658.00 O41.00x0 658.00 O41.00x1 658.00 O41.00x2 658.00 O41.00x3 658.00 O41.00x4 658.00 O41.00x5 658.00 O41.00x9 658.03 O41.01x0 658.03 O41.01x1 658.03 O41.01x2 658.03 O41.01x3 658.03 O41.01x4 658.03 O41.01x5 658.03 O41.01x9 658.03 O41.02x0 658.03 O41.02x1 658.03 O41.02x2 658.03 O41.02x3 658.03 O41.02x4 658.03 O41.02x5 658.03 O41.02x9 658.03 O41.03x0 658.03 O41.03x1 658.03 O41.03x2 658.03 O41.03x3 658.03 O41.03x4 658.03 O41.03x5 658.03 O41.03x9 658.10 O42.00

658.10 O42.019 658.10 O42.90 658.10 O42.919 658.13 O42.011 658.13 O42.012 658.13 O42.013 658.13 O42.911 658.13 O42.912 658.13 O42.913 658.20 O42.10 658.20 O42.119 658.23 O42.111 658.23 O42.112 658.23 O42.113 658.30 O75.5 658.33 O75.5 658.40 O41.1090 658.40 O41.1091 658.40 O41.1092 658.40 O41.1093 658.40 O41.1094 658.40 O41.1095 658.40 O41.1099 658.40 O41.1290 658.40 O41.1291 658.40 O41.1292 658.40 O41.1293 658.40 O41.1294 658.40 O41.1295 658.40 O41.1299 658.40 O41.1490 658.40 O41.1491 658.40 O41.1492 658.40 O41.1493 658.40 O41.1494 658.40 O41.1495 658.40 O41.1499 658.43 O41.1010 658.43 O41.1011 658.43 O41.1012 658.43 O41.1013 658.43 O41.1014 658.43 O41.1015 658.43 O41.1019 658.43 O41.1020 658.43 O41.1021 658.43 O41.1022 658.43 O41.1023 658.43 O41.1024 658.43 O41.1025 658.43 O41.1029

658.43 O41.1030 658.43 O41.1031 658.43 O41.1032 658.43 O41.1033 658.43 O41.1034 658.43 O41.1035 658.43 O41.1039 658.43 O41.1210 658.43 O41.1211 658.43 O41.1212 658.43 O41.1213 658.43 O41.1214 658.43 O41.1215 658.43 O41.1219 658.43 O41.1220 658.43 O41.1221 658.43 O41.1222 658.43 O41.1223 658.43 O41.1224 658.43 O41.1225 658.43 O41.1229 658.43 O41.1230 658.43 O41.1231 658.43 O41.1232 658.43 O41.1233 658.43 O41.1234 658.43 O41.1235 658.43 O41.1239 658.43 O41.1410 658.43 O41.1411 658.43 O41.1412 658.43 O41.1413 658.43 O41.1414 658.43 O41.1415 658.43 O41.1419 658.43 O41.1420 658.43 O41.1421 658.43 O41.1422 658.43 O41.1423 658.43 O41.1424 658.43 O41.1425 658.43 O41.1429 658.43 O41.1430 658.43 O41.1431 658.43 O41.1432 658.43 O41.1433 658.43 O41.1434 658.43 O41.1435 658.43 O41.1439 658.80 O41.8x90 658.80 O41.8x91

658.80 O41.8x92 658.80 O41.8x93 658.80 O41.8x94 658.80 O41.8x95 658.80 O41.8x99 658.83 O41.8x10 658.83 O41.8x11 658.83 O41.8x12 658.83 O41.8x13 658.83 O41.8x14 658.83 O41.8x15 658.83 O41.8x19 658.83 O41.8x20 658.83 O41.8x21 658.83 O41.8x22 658.83 O41.8x23 658.83 O41.8x24 658.83 O41.8x25 658.83 O41.8x29 658.83 O41.8x30 658.83 O41.8x31 658.83 O41.8x32 658.83 O41.8x33 658.83 O41.8x34 658.83 O41.8x35 658.83 O41.8x39 658.90 O41.90x0 658.90 O41.90x1 658.90 O41.90x2 658.90 O41.90x3 658.90 O41.90x4 658.90 O41.90x5 658.90 O41.90x9 658.93 O41.91x0 658.93 O41.91x1 658.93 O41.91x2 658.93 O41.91x3 658.93 O41.91x4 658.93 O41.91x5 658.93 O41.91x9 658.93 O41.92x0 658.93 O41.92x1 658.93 O41.92x2 658.93 O41.92x3 658.93 O41.92x4 658.93 O41.92x5 658.93 O41.92x9 658.93 O41.93x0 658.93 O41.93x1 658.93 O41.93x2 658.93 O41.93x3

658.93 O41.93x4 658.93 O41.93x5 658.93 O41.93x9 V23.0 O09.00 V23.0 O09.01 V23.0 O09.02 V23.0 O09.03 V23.1 O09.10 V23.1 O09.11 V23.1 O09.12 V23.1 O09.13 V23.2 O09.291 V23.3 O09.40 V23.3 O09.41 V23.3 O09.42 V23.3 O09.43 V23.41 O09.211 V23.41 O09.212 V23.41 O09.213 V23.41 O09.219 V23.49 O09.291 V23.49 O09.292 V23.49 O09.293 V23.49 O09.299 V23.5 O09.291 V23.5 O09.292 V23.5 O09.293 V23.5 O09.299 V23.7 O09.30 V23.7 O09.31 V23.7 O09.32 V23.7 O09.33 V23.81 O09.511 V23.81 O09.512 V23.81 O09.513 V23.81 O09.519 V23.82 O09.521 V23.82 O09.522 V23.82 O09.523 V23.82 O09.529 V23.83 O09.611 V23.83 O09.612 V23.83 O09.613 V23.83 O09.619 V23.84 O09.621 V23.84 O09.622 V23.84 O09.623 V23.84 O09.629 V23.89 O09.70 V23.89 O09.71 V23.89 O09.72

V23.89 O09.73 V23.89 O09.891 V23.89 O09.892 V23.89 O09.893 V23.89 O09.899 V23.9 O09.90 V23.9 O09.91 V23.9 O09.92 V23.9 O09.93 Published: Policy Update, July, 2004 Policy Update, August 2007 Provider Update, June 2008 Provider Update, July 2012 INTERNAL USE ONLY: 12/30/11: RSS closed as diagnosis codes have been added to the system. References: 1. American Medical Association: CPT® 2008: Surgery:Maternity Care and Delivery

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice.