Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance

MP 10.01.02

Nurse-Midwives


Medical Policy
Section
Administrative
Original Policy Date
11/30/96
Last Review Status/Date
Reviewed by consensus/3:2003
Issue
3:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

A certified nurse-midwife (CNM) is an individual who is educated in both nursing and midwifery, and who is certified according to the requirements of the American College of Nurse-Midwives and the licensing requirements of the state in which he or she practices.

The practice of CNMs focuses on women’s health care, pregnancy, childbirth, the postpartum period, care of the newborn, family planning, and the gynecological needs of women.


Policy

Services provided by a certified nurse-midwife are eligible for coverage when the following conditions are met:

  • CNM functions as a member of a health-care team, which includes a qualified physician;
  • CNM must be licensed and certified in the jurisdiction in which he or she practices and be in compliance with the legal requirements of that jurisdiction; and
  • Services provided meet all other standards of medical coverage.


Policy Guidelines

The following services may be rendered by a CNM, contingent upon state licensure:

  • Normal prenatal care;
  • Normal delivery;
  • Postnatal care;
  • Routine neonatal care;
  • Well-woman care;
  • Treatment of minor non-surgical gynecologic conditions, e.g., vaginal infections;
  • Family planning.

These services include routine:

  • Office visits;
  • Perinatal screening and diagnostic tests;
  • Performance and repair of episiotomy and repair of lacerations;
  • Pap smears;
  • Ordering of a screening mammogram;
  • Common screening and diagnostic tests necessary for well-woman care and the treatment of minor gynecologic conditions;
  • Prescription of medications for above-listed conditions.

A CNM, while functioning as a member of a health-care team that includes a qualified physician, does not require the physical presence of a physician when patient care is given. However, there must be guidelines that define individual and shared responsibilities of each health-care provider, e.g., immediate availability of a physician when complications arise during delivery, as well as periodic evaluations of services rendered, chart review, case review, etc.


Benefit Application

BlueCard/National Account Issues

Claims are not reimbursed to both a CNM and an obstetrician for the delivery. When both a physician and a CNM are involved in prenatal care and/or delivery, the total allowance for both providers should not exceed the total normally allowed when only one provider is involved in the care of the patient. Additional benefits may be appropriate and necessary, such as occurrence of complications requiring physician intervention, when medical documentation is provided.

Screening and well-woman care are contingent upon contract or certificate of coverage.

Plans determine reimbursement for hospital-based birthing centers or full-standing birthing centers that may accompany claims by a CNM.


Rationale

A search of the literature was completed through the MEDLINE database for the period of January 1991 through July 1996. The search strategy focused on references containing the following Medical Subject Heading:


 
– Nurse-Midwives (narrowed using guideline, parameter, or indication)

Research was limited to English-language journals on humans.

 

Codes

Number

Description

CPT 

59400 

Routine obstetric care, including antepartum care, vaginal delivery, and pospartum care 

 

59409 

Vaginal delivery only 

 

59410 

Vaginal delivery, including postpartum care 

 

59430 

Postpartum care only 

 

59610 

Routine obstetric care, including antepartum care and postpartum care, after previous cesarean delivery 

 

59612 

Vaginal delivery only, after previous cesarean delivery 

 

59614 

Vaginal delivery after previous cesarean delivery including postpartum care 

 

76092 

Screening mammography, bilateral 

 

99385 – 99387 

Well-woman care (office visit for preventive medicine, new patient) 

 

99395 – 99397 

Well-woman care (office visit for preventive medicine, established patient) 

ICD-9 Procedure 

73.6 

Episiotomy (includes routine repair) 

 

75.50 – 75.69 

Repair of obstetrical laceration 

 

87.37 

Mammogram 

 

91.46 

Pap smear 

ICD-9 Diagnosis 

V22.0 

Encounter for prenatal care (normal, first pregnancy) 

 

V22.1 

Encounter for prenatal care 

 

V24.0 

Postpartum care, immediately after delivery 

 

V24.1 

Postpartum care, lactating mother 

 

V24.2 

Postpartum care, routine follow-up 

 

V25.09 

Encounter for family planning 

 

V76.1 

Screening mammography (for malignant breast neoplasm) 

 

616.10 

Vaginal infection 

 

650 

Normal delivery 

HCPCS 

Q0091 

Pap smear obtaining, preparing, and conveying to lab 

Type of Service 

OB/GYN 

Place of Service 

Birthing center
 
Home
 


Index

Certified nurse-midwives
Nurse-midwives


Policy History

Date Action Reason
11/30/96 Add to Administrative section New policy
4/01/98 Replace policy Policy reviewed, formatting changes only
4/15/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled


Search for Policies

Policy Feedback