Section 12000, Clinical Policy

Revision 19-0; Effective July 1, 2019

 

 

This section describes the requirements and recommendations for FPP contractors pertaining to the delivery of direct clinical services to patients. In addition to the requirements and recommendations found within this section, contractors should develop protocols consistent with national evidence-based guidelines appropriate to the target population.

All providers must offer the following core family planning services:

 

12100 Covered Services

Revision 19-0; Effective July 1, 2019

 

The FPP seeks to promote the general and reproductive health of Texas residents by providing safe and effective family planning services to men and women through 64 years of age who reside in Texas and meet program eligibility requirements.

The following services are covered under the FPP:

 

12110 Requirement for Documentation of Reproductive Health Services

Revision 19-0; Effective July 1, 2019

 

All individuals should receive services related to reproductive health and/or contraception at least annually Individuals using long-acting reversible contraception (intrauterine device, implantable hormonal contraceptive agent) and patients who have undergone permanent sterilization may continue to receive services under the program if they meet eligibility requirements. 

The guiding principle of the FPP is to improve the reproductive health of women and men to ensure that every pregnancy and every baby are healthy. At each patient encounter, including encounters for treatment of other conditions (e.g., follow up of an abnormal Pap smear), the provider must educate the patient on how the service being provided relates to reproductive health or contraception, and this must be documented in the patient record.

For individuals who have undergone sterilization, and women who are post-menopausal or have had a hysterectomy, this counseling and documentation are not required when receiving covered services. This must be documented in the medical record at least annually.

 

12111 Individual Health Records and Documentation of Encounters

Revision 19-0; Effective July 1, 2019

 

Providers must ensure that a patient health record (medical record) is created for every individual who obtains clinical services (also see Section 5000, Client Records Management).

All patient health records must be:

The individual health record must include:

 

12120 Initial Clinical Visit

Revision 19-0; Effective July 1, 2019

 

At the initial clinical visit or an early subsequent visit, a comprehensive health history must be taken to include, in addition to the elements required for the individual health record in Section 12110 above (adapt, as appropriate, to the gender of the person):

At every subsequent visit, including the annual primary health care and problem visits, the record must be updated, as appropriate, and the reason for the visit and current health status documented.

 

12121 Annual Comprehensive Family Planning Visit, Physical Examination and Testing

Revision 19-0; Effective July 1, 2019

 

The annual family planning visit offers an excellent opportunity for providers to address issues of wellness and health risk reduction, as well as addressing any current findings or patient concerns. The annual visit must include an update of the person’s health record, as described in the individual health record in Section 12110 above, as well as appropriate screening, assessment, counseling and immunizations based on the individual’s age, risk factors, preferences and concerns.

All individuals must undergo a physical examination annually as part of the family planning visit. This can be deferred to a later date if the person’s current history and health status do not suggest issues requiring more urgent examination. However, the annual physical examination should not be deferred longer than six months, unless the clinician identifies a compelling reason for extended deferral. Such reason must be documented in the individual’s record. Any breast or pelvic examination should be performed only with the consent of the person. Individuals must be offered a suitable method of contraception, such as oral contraceptives, without delay even if the physical examination is put off temporarily or an otherwise asymptomatic individual declines any or all components of the examination.

It is recommended that the family planning visit include all the following components at least annually, in addition to any other appropriate elements as suggested by history and presenting signs and symptoms (all findings, including tests, results and the individual’s notification of results, should be documented in the medical record, as well as an individual’s refusal or other reason for not testing or performing a specified part of the examination):

 

12122 Counseling and Education

Revision 19-0; Effective July 1, 2019

 

All individuals must receive accurate person-centered education and counseling in their preferred language, presented in a way they are able to understand and to demonstrate their understanding, and documented in the medical record. The intent of individual education is to enable the person to understand the range of available services and how to access them, to make informed decisions about family planning, to reduce personal health risk and to understand the importance of recommended tests, health promotion and disease prevention strategies.

Specific clinical policies must be in place to address counseling and other services provided to adolescents 17 years of age and younger, to include the following at a minimum:

Details of appropriate educational interventions are included in this manual. In addition, links are provided to information of use to individuals and educators at the end of most sections.

 

12130 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 19-0; Effective July 1, 2019

 

Providers must develop and maintain policies and procedures to ensure proper timely follow-up and continuity of care, to include at a minimum:

Before a person is considered lost to follow-up, the contractor must make at least three documented separate attempts to contact the person, using an accelerated protocol where subsequent attempts involve a more intensive effort to contact the person. Examples: A telephone call on the first attempt, a letter by regular mail on the second attempt and a certified letter on the third attempt. Providers should develop processes that are adapted to the circumstances of the population they serve, and adapt their usual processes based on their knowledge of the circumstances and preferences of the individual they are attempting to contact. 

 

12131 Problem Visits

Revision 19-0; Effective July 1, 2019

 

For all problem visits, the following elements must be documented in the medical record:

 

12132 Referrals

Revision 19-0; Effective July 1, 2019

 

When a person is referred to another provider of services for consultation or continuation of care, the chart must reflect a record of the purpose for the referral, the name of the provider consulted or referred to, counseling of the person regarding the purpose of the referral and answering any questions the person has about the referral. Pertinent individual information and appropriate portions of the medical record must be provided to the referral clinician and must also be documented in the medical record. The results of the consultation or referral must be followed up on and documented in the medical record.

When services covered under the FPP are to be provided by referral, the contractor must establish a written agreement with a referral resource for the provision of services and reimbursement of costs and ensure that the patient is not charged by the referral resource for these services.

Contractors must maintain a written policy reflecting these requirements for referral activities.

 

12133 Prescriptive Authority Agreements

Revision 19-0; Effective July 1, 2019

 

When services are provided by an advanced practice registered nurse (APRN) and/or physician assistant, it is the responsibility of the contractor to ensure that a properly executed prescriptive authority agreement (PAA) is in place for each provider, as required by Texas Administrative Code Title 22, Part 9, Chapter 193. This is true whether the provider is employed by the contractor or is providing services by subcontract with, or referral by, the contractor. The PAA must meet all the requirements delineated in the Texas Occupations Code, Chapter 157, including but not limited to, the following minimum criteria:

The PAA need not describe the exact steps that an APRN or physician assistant must take with respect to each specific condition, disease or symptom. The PAA and any amendments must be reviewed at least annually, dated and signed by the parties to the agreement. A copy of the current PAA must be maintained on-site where the APRN or physician assistant provides care.

 

12134 Standing Delegation Orders

Revision 19-0; Effective July 1, 2019

 

When services are provided by unlicensed and licensed personnel, other than advanced practice nurses or physician assistants, whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written standing delegation orders (SDOs) in place. SDOs are distinct from specific orders written for an individual. SDOs are instructions, orders, rules, regulations or procedures that specify under what set of conditions and circumstances actions should be instituted. The SDOs delineate under what set of conditions and circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting and provide authority for use with individuals when a physician or advance practice provider is not on the premises, and/or prior to being examined or evaluated by a physician or advanced practice provider. Example: An SDO for assessment of blood pressure/blood sugar which includes an RN, LVN or NLHP that will perform the task, the steps to complete the task, the normal/abnormal range and the process of reporting abnormal values.

Other applicable SDOs when a physician is not present on-site may include, but are not limited to:

The SDOs must be reviewed, signed and dated by the supervising physician who is responsible for the delivery of medical care covered by the orders and other appropriate staff at least annually, and maintained on-site.

 

12140 References

Revision 19-0; Effective July 1, 2019

 

American Academy of Family Physicians (2017). Summary of recommendations for clinical preventive services. AAFP Policy Action Order No. 1968. Available at http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf.

American College of Obstetricians and Gynecologists (2012). Committee opinion 534: Well-woman visit. Obstet Gynecol 120: 421-424. Available at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Well-Woman_Visit.

Centers for Disease Control and Prevention. Content of care for women website. Available at http://www.cdc.gov/preconception/careforwomen/index.html.

Centers for Disease Control and Prevention. Clinical content of care for men website. Available at http://www.cdc.gov/preconception/careformen/index.html.

Centers for Disease Control and Prevention (2014). Providing quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf.

Centers for Disease Control and Prevention (2016). Update: Providing quality family planning services - Recommendations from CDC and the U.S. Office of Population Affairs, 2015. MMWR 65(9); 231-234. Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.

Centers for Disease Control and Prevention. Immunization schedules website. Available at http://www.cdc.gov/vaccines/schedules/.

 

12200 Family Planning and Contraceptive Services

Revision 19-0; Effective July 1, 2019

 

12210 Reproductive Life Plan

Revision 19-0; Effective July 1, 2019

 

Providers should encourage all individuals to develop a reproductive life plan, which is an outline of each person’s plan for having children. Questions such as the following can be useful in helping individuals to develop the plan:

Of course, providers and individuals should understand that such plans can change with time. Providers should take the individual’s stated plan into account in counseling on contraceptive and family planning services.

 

12220 Contraceptive Counseling and Education

Revision 19-0; Effective July 1, 2019

 

At each encounter for services, individuals must receive patient-centered counseling and education to enable them to make informed decisions about family planning, including information on preventing STDs/STIs and HIV, the results of the physical examination and other testing, method-specific counseling as described below, and other counseling as indicated by the history and clinical evaluation.

Providers must offer individuals a wide array of contraceptive options appropriate for the person’s health status and reproductive plan. A six-step approach that seeks to engage the person in the decision-making process, while addressing individual personal and cultural preferences, will improve individual satisfaction and the likelihood that the selected method will be used correctly and consistently.

 

12221 Relative Method Effectiveness

Revision 19-0; Effective July 1, 2019

 

The following contraceptive methods are approved for reimbursement under the FPP. (see pharmacy requirements for FPP contractors in Section 9000, Pharmacy, and Section 12222.2, Specific Method Access Requirements for Contractors). 
It is the contractor’s responsibility to ensure that all contraceptive methods approved for reimbursement by the FPP are made available at no additional charge to the individual.

Relative method effectiveness (range of effectiveness for 100 women using the method for one year) is indicated in parentheses, if reported values are available.  Actual effectiveness depends on correctness and consistency of use. Higher rates of effectiveness are seen with perfect use. Real-world effectiveness is generally reflected in the lower end of the effectiveness range.

*Long-acting reversible contraceptive methods.

 

12222 Long-Acting Reversible Contraceptive (LARC) Methods

Revision 19-0; Effective July 1, 2019

 

Because of their safety, reversibility, ease of use and very high real-world effectiveness, providers are encouraged to make LARC agents and devices (i.e., the intrauterine device and the subdermal contraceptive implant) available to all who are candidates for their use. See Long-Acting Reversible Contraception Program from the American Congress of Obstetricians and Gynecologists for information and resources on the use of LARCs.

For more information on implementing a program to provide LARCs, see the Texas LARC Toolkit on the Healthy Texas Women website.

 

12222.1 Consent for Sterilization

Revision 19-0; Effective July 1, 2019

 

For individuals who choose male or female sterilization, two consent forms are required to be signed by the person after counseling on method-specific risks and benefits is provided and all the person’s questions have been answered:

 

12222.2 Specific Method Access Requirements for Contractors

Revision 19-0; Effective July 1, 2019

 

The table below outlines the requirements for on-site availability of contraceptive methods and anti-infective agents for FPP contractors:

Contraceptive Method or Anti-infective Agent On-site Availability Required
  Class D Pharmacy Class D Pharmacy Exempt
Anti-infective agents for treatment of STDs/STIs  
Barrier methods and spermicides

Injectable hormonal contraceptives

Oral contraceptives

 

Transdermal hormonal contraceptive (patch) and/or vaginal hormonal contraceptive (ring)

 

Sexual abstinence education and counseling

 

12223 Contraceptive Methods that May Be Provided by Referral

Revision 19-0; Effective July 1, 2019

 

If the clinicians associated with an FPP contractor do not provide covered contraceptive services that require a special level of training or expertise (e.g., sterilization, intrauterine device, hormonal implant and diaphragm fitting), these services may be offered by referral to another provider at no additional cost to the individual. FPP contract clinics that offer such services by referral must have a written agreement with the referral provider to offer the method or service under this condition.

Notes:

 

12224 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Centers for Disease Control and Prevention (2014). Providing quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm (web) http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf (PDF).

Centers for Disease Control and Prevention (2016). Update: Providing quality family planning services - Recommendations from CDC and the U.S. Office of Population Affairs, 2015.  MMWR 65(9); 231-234. Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.

Centers for Disease Control and Prevention. U.S. selected practice recommendations for contraceptive use, 2016. MMWR 65(No. 4). Available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html (web) https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf.

Resource for Patients and Educators

Association of Reproductive Health Professionals. Method Match. Online decision support tool to help patients compare and select from different methods of contraception. Includes information on relative effectiveness of methods. Available at http://www.arhp.org/methodmatch/.

Resource for Providers

American Congress of Obstetricians and Gynecologists. Long-acting reversible contraception program web page. Provides information, clinical guidance and educational materials on long-acting reversible contraceptives. Available at https://www.acog.org/About_ACOG/ACOG_Departments/Long_Acting_Reversible_Contraception

 

12230 Preconception Services

Revision 19-0; Effective July 1, 2019

 

The goal of preconception care is optimizing the health of every woman to lay the foundation for the best possible outcome of every pregnancy. Because almost half of all pregnancies in the United States are unplanned, and most pregnancies occur in women who did not have a specific preconception care visit prior to becoming pregnant, providers should keep preconception care in mind at every encounter with a woman of childbearing potential.

Good preconception care incorporates all components of general health care as described elsewhere in this manual. Attention should be paid to the following components:

 

12231 References and Resources

Revision 19-0; Effective July 1, 2019

References

American Academy of Pediatrics/American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care 7th Ed. (2012). Ch. 5, pp. 95-106.

American College of Obstetricians and Gynecologists. Committee opinion 313: The importance of preconception care in the continuum of women’s health care.  Obstet Gynecol (2005). 106: 665-666. Available at http://www.acog.org/Resources_And_Publications/~/link.aspx?_id=75AD1BF47A76489F8E719EA5E3F22797&_z=z.

Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care – United States. MMWR (2006). 55(RR06): 1-23.  Available at http://www.cdc.gov/mmWR/PDF/rr/rr5506.pdf.

Organization of Teratology Information Specialists. Mother to Baby: Medications and more during pregnancy and breastfeeding. Available at http://mothertobaby.org/fact-sheets-parent/.  (Provides information for patients and health care providers on teratogenic risk of drugs and other exposures in pregnancy.)

Resources for Patients and Providers

American Society for Reproductive Medicine. Available at http://www.reproductivefacts.org/. (Information for patients on a variety of topics related to fertility and infertility.)

Centers for Disease Control and Prevention. Content of care for women website. Available at http://www.cdc.gov/preconception/careforwomen/index.html.

Centers for Disease Control and Prevention. Clinical content of care for men website. Available at http://www.cdc.gov/preconception/careformen/index.html.

Centers for Disease Control and Prevention. Preconception health and health care web site. Contains links to resources for patients, providers and patient educators on planning for a healthy pregnancy. Available at http://www.cdc.gov/preconception/index.html.

 

12300 Screenings

Revision 19-0; Effective July 1, 2019

 

 

12310 Cervical Cancer Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for the FPP and does not include guideline recommendations for individuals outside this range.

Guidelines were reviewed from a variety of medical specialty organizations and U.S. government agencies. Where a slight divergence was found among guidelines from different organizations, an attempt was made to synthesize the recommendations so that all recommendations are represented cohesively in the summary below. 

Most cases of cervical cancer occur in women who have never had screening or have had inadequate screening. It is estimated that half of women who receive a diagnosis of cervical cancer have never had cervical cytology testing and an additional 10% have not had screening in the five years prior to the diagnosis of cancer. Providers are encouraged to implement and participate in programs aimed at increasing the percentage of women in their communities who receive indicated cervical cancer screening.

General Considerations

 

12311 Screening Frequency and Response to Abnormal Findings

Revision 19-0; Effective July 1, 2019

 

Discontinuation of Screening

For women in the FPP age group, screening should be discontinued after a hysterectomy with removal of the cervix in individuals with no prior history of CIN 2 or greater.

 

12312 References

Revision 19-0; Effective July 1, 2019

 


American Society for Colposcopy and Cervical Pathology (2013). Consensus guidelines for managing abnormal cervical cancer screens and CIN/AIS. Available at http://www.asccp.org/asccp-guidelines.
Huh, W. K., Ault, K. A., Chelmow, D., Davey, D. D., Goulart, R. A., Garcia, F. A., Einstein, M. H. (2015). Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol, 136(2), 178-182.

Practice Bulletin No. 168: Cervical cancer screening and prevention. (2016). Obstet Gynecol, 128(4), e111-e130.

U.S. Department of Health and Human Services Panel on opportunistic infections in HIV-infected adults and adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health and the HIV Medicine Association of the Infectious Diseases Society of America. Available at https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0.

U.S. Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Wong, J. B. (2018). Screening for cervical cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674-686.

 

12320 Breast Cancer Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this range.

Risk Screening and Individual Counseling

All females should have an assessment of their risk for breast cancer, updated periodically, to include the individual’s age and ethnicity, personal and family history of breast cancer, other relevant genetic predisposition to breast cancer and any history of chest radiation (particularly before age 30). A risk calculator is available from the National Cancer Institute for an individual’s five-year risk of developing breast cancer (for women age 35 and older).

All individuals should be counseled on breast awareness, advised to be familiar with their breasts and to promptly report any changes (such as a mass, lump, thickening or nipple discharge).

 

12321 Screening Frequency

Revision 19-0; Effective July 1, 2019

 

The following considerations* apply to women age 40 and older who do not have preexisting breast cancer or other high-risk breast lesion and who do not have a known underlying genetic mutation (such as a BRCA1 or 2 mutations, or other familial breast cancer syndrome) or a history of chest radiation at an early age. 

More frequent or earlier screening mammography may be considered in women with increased or uncertain individual breast cancer risk and in other circumstances where the balance of potential benefits and harms of screening is felt to justify it.

*Note: The recommendations for frequency of mammography screening described above come from the U.S. Preventive Services Task Force Recommendation Statement on Screening for Breast Cancer. The National Comprehensive Cancer Network recommends annual screening mammography be offered to all asymptomatic women age 40 and older. Links to both guidelines are provided in Section 12323, References and Resources.

 

12322 Follow-up and Referral for Treatment

Revision 19-0; Effective July 1, 2019

 

Any individual with an abnormality identified on screening or a specific breast complaint (including, but not limited to a mass, lump, thickening or nipple discharge) should be evaluated, as indicated, in a timely manner. Providers should have procedures in place to ensure appropriate individual education and counseling, referral for further evaluation (including additional testing and biopsy) when indicated, communication and coordination with the person and other providers, and proper follow-up through the conclusion of the case.

For persons who require referral for services beyond those available through the contracted provider, contractors are encouraged, whenever possible, to refer those persons to an HHSC Breast and Cervical Cancer Services (BCCS) contractor.  Information is available at https://hhs.texas.gov/Doing-Business-HHS/Provider-Portals/Health-Services-Providers/Womens-Health-Services/Breast-Cervical-Cancer-Services.

Eligible individuals in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. Information is available at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/womens-health-services/breast-cervical-cancer-services/breast-cervical-cancer-treatment-information.

 

12323 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Siu, AL. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement.Ann Intern Med. 2016;164(4):279-296. Available at http://annals.org/article.aspx?articleid=2480757

National Comprehensive Cancer Network (2018). NCCN clinical practice guidelines in oncology: Breast cancer screening and diagnosis. Version 2.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_screening.

Additional Reading

National Comprehensive Cancer Network (2018). NCCN clinical practice guidelines in oncology: Breast cancer risk reduction. Version 2.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_risk.

National Comprehensive Cancer Network (2017). NCCN clinical practice guidelines in oncology: Genetic/familial high-risk assessment: Breast and ovarian. Version 1.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_risk.

Information for Patients

National Cancer Institute. Mammograms patient information. Available at http://www.cancer.gov/types/breast/mammograms-fact-sheet.

National Cancer Institute. Breast Cancer – Patient Version. Available at http://www.cancer.gov/types/breast.

Online Provider Resources

National Cancer Institute. Breast Cancer Risk Assessment Tool. Available at http://www.cancer.gov/bcrisktool/Default.aspx.

 

12330 Sexually Transmitted Disease/Infection (STD/STI) Screening and Treatment

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this range.

Screening and treatment of STDs/STIs must follow the current guidelines for screening and treatment from the Centers for Disease Control and Prevention (CDC). A risk assessment should be done for all individuals to determine what testing is indicated and documented in the medical record. Following is a brief overview of STD/STI screening recommendations (for more detailed information, go to the CDC screening links above).

 

12331 HIV Screening

Revision 19-0; Effective July 1, 2019

 

 

12332 Chlamydia and Gonorrhea Testing

Revision 19-0; Effective July 1, 2019

 

 

12333 Herpes Simplex Virus (HSV) Screening

Revision 19-0; Effective July 1, 2019

 

 

12334 Syphilis Screening (Men and Nonpregnant Women)

Revision 19-0; Effective July 1, 2019

 

 

12335 Other Screening and Pregnant Women

Revision 19-0; Effective July 1, 2019

 

Screening for other infections and more frequent screening should be considered as appropriate based on the person’s condition, risk factors and concerns.

Pregnant Women

 

12336 Patient-Delivered Partner Therapy (PDPT)

Revision 19-0; Effective July 1, 2019

 

PDPT is the practice of providing therapy to the sexual partner(s) of a person being treated for chlamydia or gonorrhea without first developing a patient-clinician relationship with the partner(s). Untreated partners can reinfect treated individuals and expose others to infection.

Providers are encouraged to implement PDPT by providing individuals who are being treated for either chlamydia or gonorrhea with medications or prescriptions the partner(s) can use to be treated as well. 

Providers may not receive reimbursement for providing partner treatment under this policy to persons who have not been patients.

 

12337 References

Revision 19-0; Effective July 1, 2019

 

American College of Obstetricians and Gynecologists. Committee Opinion No. 598: The initial reproductive health visit. Obstet Gynecol (2014) 123: 1143-1147. Available at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Adolescent_Health_Care/The_Initial_Reproductive_Health_Visit.

Branson, BM., et al. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health care settings. MMWR (2006) 55(RR14): 1-17.  Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

Centers for Disease Control and Prevention. Genital herpes. Available at http://www.cdc.gov/std/Herpes/default.htm.

Centers for Disease Control and Prevention. Pregnant women, infants and children: An opt-out approach to HIV screening. Available at http://www.cdc.gov/hiv/group/l/pregnantwomen/opt-out.html.

Centers for Disease Control and Prevention. Sexually transmitted diseases:
Treatment. Available at http://www.cdc.gov/std/treatment/default.htm.

Centers for Disease Control and Prevention. STD and HIV Screening Recommendations. Available at http://www.cdc.gov/std/prevention/screeningreccs.htm.

U.S. Preventive Services Task Force. Screening for syphilis infection in nonpregnant adults and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA (2016) 315(21): 2321-2327. Available at http://jamanetwork.com/journals/jama/fullarticle/2526645.

Expedited (Patient-Delivered) Partner Therapy (information for patients and providers):

Centers for Disease Control and Prevention. Expedited partner therapy website. Available at http://www.cdc.gov/std/ept/.

Texas Dept. of State Health Services. Expedited partner therapy website. Available at http://www.dshs.state.tx.us/hivstd/ept/default.shtm.

 

12340 Diabetes Mellitus Screening

Revision 19-0; Effective July 1, 2019

 

Who Should Be Screened for Diabetes

The criteria below apply to nonpregnant patients only.

Risk Factors for Diabetes

 

12341 Diagnostic Criteria

Revision 19-0; Effective July 1, 2019

 

Any one or more of the following results, confirmed on repeat testing, meets the criteria for a diagnosis of diabetes (repeat testing for confirmation is not required in the presence of unequivocal clinical hyperglycemia):

Test Criteria to Diagnose Diabetes Mellitus Comments
Fasting plasma glucose Greater than or equal to 126 mg/dL (7.0 mmol/L) After no caloric intake for a minimum of eight hours.
Oral glucose tolerance test (with a 75-g glucose load) Two-hour glucose greater than or equal to 200 mg/dL (11.1. mmol/L)  
Hemoglobin A1C Greater than or equal to 6.5% (48 mmol/mol) For diagnosis of type I diabetes in individuals with acute hyperglycemic symptoms, blood glucose testing is preferred.
Random plasma glucose Greater than or equal to 200 mg/dL (11.1. mmol/L) If this occurs in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia, confirmation by repeat testing is not required.

Table: Diagnostic Criteria for Diabetes Mellitus. All initial results should be confirmed with repeat testing.

 

12342 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

American College of Obstetricians and Gynecologists (2013). Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 122 406-416.

American Diabetes Association. Standards of medical care in diabetes – 2018. Diabetes Care (2018); 41(Suppl. 1). Available at  http://care.diabetesjournals.org/content/41/Supplement_1.

Resources for Patients and Educators

American Diabetes Association at http://www.diabetes.org.

American Diabetes Association Diabetes Pro website (information for providers of care) at http://professional.diabetes.org.

American Diabetes Association Diabetes Educators (information and resources for both patients and educators) at http://professional.diabetes.org/diabetes-education.

Centers for Disease Control and Prevention. Adult BMI calculator. Available at http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html.

Centers for Disease Control and Prevention. BMI calculator for child and teen. Available at http://nccd.cdc.gov/dnpabmi/Calculator.aspx.

Centers for Disease Control and Prevention. Defining childhood obesity (provides definition of overweight and obesity in children and adolescents age 2 to 19, and link to BMI calculator for children and teens). Available at http://www.cdc.gov/obesity/childhood/defining.html.

National Diabetes Education Initiative (patient education handouts and links to professional resources) at http://www.ndei.org

National Institute of Diabetes and Digestive Diseases. National Diabetes Education Program (resources for patients and educators). Available at http://www.niddk.nih.gov/health-information/health-communication-programs/ndep/pages/index.aspx.

National Heart, Lung and Blood Institute Aim for a Healthy Weight at https://www.nhlbi.nih.gov/health/educational/lose_wt.

 

12350 Hypertension Screening

Revision 19-0; Effective July 1, 2019

 

All individuals, including those with hypertension, should be advised to adhere to a healthy lifestyle as described in Section 12400, Healthy Lifestyle Intervention.

Classification of BP and Diagnosis of Hypertension

In the United States, high blood pressure (BP) is the second leading cause of preventable death after cigarette smoking and is the most important modifiable risk factor for death due to cardiovascular disease. Because hypertension is generally asymptomatic, it is important that all persons be screened at least annually for elevated BP.

The following table provides guidance on diagnosis of hypertension in adults. Recent guidelines emphasize greater reliance on home BP monitoring to aid in the diagnosis of hypertension when clinic readings are high normal, borderline high or elevated. It is generally agreed that clinic BP measurements are often higher than home BP measurements, particularly in the higher ranges of BP.

BP (mm Hg) Category
Less than 120/80 Normal
120-129/Less than 80 Elevated
130-139/80-89 Stage 1 hypertension
Greater than or equal to 140/90 Stage 2 hypertension

Measurement of BP

Instructions for Home BP Monitoring

Nonpharmacologic Intervention

All patients, regardless of BP category should receive instruction in healthy lifestyle habits, with regular reinforcement of teaching. 

 

12351 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Carey, R. M., Whelton, P. K. (2018). Prevention, detection, evaluation and management of high blood pressure in adults: Synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med, 168(5), 351-358. Available at http://annals.org/aim/fullarticle/2670318/prevention-detection-evaluation-management-high-blood-pressure-adults-synopsis-2017.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Hypertension, 71(6), e13-e115. Available at http://hyper.ahajournals.org/content/71/6/e13.long.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Executive Summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol, 71(19), 2199-2269. Available at https://www.sciencedirect.com/science/article/pii/S073510971741518X?via%3Dihub.

Resources for Patients and Educators

American Heart Association. High blood pressure. Provides information on the meaning and importance of high blood pressure, risks for, and prevention of, high blood pressure, blood pressure monitoring and treatment of high blood pressure. Available at http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/High-Blood-Pressure_UCM_002020_SubHomePage.jsp.

National Heart, Lung and Blood Institute. Description of high blood pressure. Provides a plain language discussion of the prevention, diagnosis and treatment high blood pressure. Available at http://www.nhlbi.nih.gov/health/health-topics/topics/hbp.

Resources for Providers

American Society of Hypertension. Hypertension Guidelines at http://www.ash-us.org/About-Hypertension/Hypertension-Guidelines.aspx.

 

12360 High Cholesterol Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this eligibility range.

The diagnosis and treatment of elevated blood cholesterol is a complex subject and a complete discussion is beyond the scope of this manual. For more information, providers are referred to Section 12362, References and Resources, and relevant textbooks.

Rationale for Cholesterol Screening

Evidence shows that a healthy lifestyle (following a heart healthy diet, maintaining a healthy weight, regular exercise and avoidance of tobacco products) reduces the risk of cardiovascular disease. In certain persons with specific risk factors, cholesterol-lowering medications (i.e., statins) can further reduce the risk of an adverse health event. Measurement of blood cholesterol is a component of the individual risk assessment in some patients.

Who Should Be Screened for High Cholesterol

No recommendation is made regarding routine screening in men age 20 through 35 or in women age 20 or older without increased risk of CHD.

Risk Factors

Increased risk of CHD is defined by the presence of any one of the risk factors below.  Greater risk results from the presence of multiple risk factors.

Screening Frequency

The optimal interval for screening is uncertain. Reasonable options include every five years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels.

An age at which to stop screening has not been established.

Screening Method

The preferred screening test for elevated cholesterol is the serum lipid panel (total cholesterol, high-density lipoprotein [HDL] cholesterol, and low-density lipoprotein [LDL] cholesterol) in the fasting or non-fasting state. If non-fasting results are used, only the total cholesterol and HDL cholesterol are reliable. Abnormal screening results should be confirmed by a repeat sample on a separate occasion, and the average of both results should be used for risk assessment.

 

12361 Evaluation of Screening Results

Revision 19-0; Effective July 1, 2019

 

Results of the lipid profile should be interpreted in the context of the individual’s risk factors and 10-year estimated risk of atherosclerotic cardiovascular disease (ASCVD), defined as acute coronary syndrome, myocardial infarction, stable or unstable angina, stroke, transient ischemic attack, coronary or other arterial revascularization procedure, or atherosclerotic peripheral arterial disease. A risk calculator for 10-year ASCVD risk is available from the American College of Cardiology and American Heart Association.

Studies have shown a benefit of statin therapy in individuals with the following risk profiles:

 

12362 References and Resources

Revision 19-0; Effective July 1, 2019

 

Stone N.J., et al. 2013 ACC/AHA Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation (2014). 129 (25 Suppl. 2): S1-S45 Available at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.

National Heart, Lung and Blood Institute. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III). NIH Publication No. 01-3670, May 2001. Available at http://www.nhlbi.nih.gov/files/docs/guidelines/atp3xsum.pdf.

U.S. Preventive Services Task Force. The Guide to Clinical Preventive Services, Lipid Disorders in Adults (2014), Page 45. Available at http://www.ahrq.gov/sites/default/files/publications/files/cpsguide.pdf.

Further Reading

Pursnani A, et al. Guideline-based statin eligibility, coronary artery calcification and
cardiovascular events. JAMA (2015) 314:134-141. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754085/.

Resources for Providers

ASCVD Risk Estimator from the American College of Cardiology. Provides an estimate of the 10-year risk of developing ASCVD. Available at http://tools.acc.org/ASCVD-Risk-Estimator/.

 

12370 Postpartum Depressing Screening

Revision 19-0; Effective July 1, 2019

 

Prevalence and Risk Factors for Postpartum Depression

As many as 80% of new mothers experience a brief episode of the “baby blues” which may last up to two weeks. Approximately 5-25% of new mothers will experience postpartum depression that warrants intervention. It typically begins in the first four to six weeks after birth of the infant but may develop any time in the first year. 

Risk factors for postpartum depression include the following:

Common signs and symptoms of postpartum depression include the following (some or none of these symptoms may be apparent):

Screening for Postpartum Depression

Providers are encouraged to review The Texas Clinician’s Postpartum Depression Toolkit for a more detailed review of screening for postpartum depression.

Because postpartum depression can be a serious and sometimes life-threatening condition, all new mothers should have screening for postpartum depression at the postpartum visit. For those who screen negative, repeat screening should be considered at a later visit or when the mother takes her baby in for a checkup.

A standardized self-administered screening tool with review and follow-up questions in a face-to-face interview with the provider will ensure consistency and efficiency in the screening process. The following postpartum depression screening tools are available online and have been validated for use in postpartum patients:

To ensure that all patients are screened without undue interruption of clinic workflow, a convenient approach to screening is the following:

 

12371 Referral for Treatment

Revision 19-0; Effective July 1, 2019

 

Individuals in need of treatment for postpartum depression should be referred to a provider of behavioral health services. Providers must have arrangements in place for appropriate referral of individuals to behavioral health providers in their area. For information on local behavioral health care providers, refer to the website of the Office of Mental Health Coordination, Texas Health and Human Services, or call 211.

Coding for Postpartum Depression Services

The following Current Procedural Terminology (CPT) codes are covered under the FPP:

99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
90791 90792      



12372 References and Resources

Revision 19-0; Effective July 1, 2019

 

American College of Obstetricians and Gynecologists Committee Opinion No. 630. Screening for perinatal depression. Obstet Gynecol (2015). 125: 1268-1271.  Available at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression.

Hirst K.P. and Moutier C.Y. Postpartum major depression. American Family Physician (2010). 82: 926-933. Available at http://www.aafp.org/afp/2010/1015/p926.html.

Norhayati M.N., et al. Magnitude and risk factors for postpartum symptoms: A literature review. J. Affect Disord. (2015). 175: 34-52.

O’Connor E, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA (2016). 315: 388-406.

Resources for Patients and Providers

American Academy of Family Physicians. Postpartum Depression webpage, information for patients and providers on postpartum depression. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression.html.

American Academy of Family Physicians. Postpartum Depression Action Plan. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression/treatment/postpartum-depression-action-plan.html.

Office of Mental Health Coordination website, Texas Health and Human Services, provides links to information for providers and patients in Texas on a variety of behavioral health topics, and a link to the Substance Abuse and Mental Health Services Administration (SAMHSA) behavioral health treatment services locator.  Available at http://mentalhealthtx.org/.

STEP-PPD Support and training to enhance primary care for postpartum depression website. Provides links to resources, including postpartum depression screening tools, online training, case studies, classroom materials, Clinician’s Pocket Guide and other materials. Available at  https://step-ppd.com/.

Texas Health and Human Services, the Texas Clinician’s Postpartum Depression Toolkit. Contains a review of the diagnosis and treatment of postpartum depression for the primary care provider, including a section on covered services, coding and billing for services provided under Texas state health care programs. Available at  https://www.healthytexaswomen.org/provider-resources#family-planning-program.

 

12380 Suicide Risk Screening

Revision 19-0; Effective July 1, 2019

 

Any individual with a positive screen based on responses to questions related to suicide risk, and any individual who expresses suicidal thoughts or ideation, must be evaluated immediately for suicide risk. If the individual is felt to be acutely at risk of suicide, she must be referred for emergent evaluation and/or hospitalization, as indicated.

 

12400 Healthy Lifestyle Intervention

Revision 19-0; Effective July 1, 2019

 

All individuals should receive a health risk survey, at least annually, to determine areas where lifestyle modifications might reduce the risk of future disease and improve health outcomes and quality of life.

Counseling on Healthy Lifestyle Choices

The following provides details for why and how to achieve some of these goals.

Diet and Nutrition

There is strong evidence that nutrition plays an important role in our risk of disease. Dietary patterns that emphasize a lower percentage of total calories from fat, reduced amounts of saturated fats, and reduced sodium intake while achieving and maintaining a healthy body weight have been shown to reduce the risk of cardiovascular disease, the most common cause of death in both men and women in the United States. No single diet has been shown to be the best and providers should counsel individuals on a variety of healthy eating patterns tailored to their health and cultural background, while preserving the pleasure of meals and eating.

Healthy Dietary Patterns

Two dietary patterns that have been shown to improve some measures of cardiovascular risk are the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean (MED) diets. Both dietary patterns emphasize reduced saturated fat and red meat, increased fiber, vegetables, fruits, fish, oils and nuts, while allowing wide freedom of food choices to accommodate eating preferences and cultural differences among individuals.

The MED diet emphasizes:

The DASH diet is:

Dietary counseling on healthy eating patterns, such as those described above, provided as a routine part of an individual encounter has been shown to reduce blood pressure in those with type 2 diabetes or risk factors for cardiovascular disease, including those with mild untreated hypertension. For individuals with normal or modestly elevated cholesterol, regardless of gender or ethnicity, following a DASH dietary pattern can reduce low-density lipoprotein cholesterol (LDL cholesterol) and high-density lipoprotein cholesterol (HDL cholesterol). Following a DASH dietary pattern can reduce blood pressure in all individuals, regardless of age, sex and ethnicity, including those with mild untreated hypertension.

Salt Intake

There is strong evidence that reducing sodium (salt) intake reduces blood pressure in individuals with normal blood pressure, as well as those with mild to moderate hypertension, regardless of sex, ethnicity and age. This holds true even if no other dietary changes are made. Therefore, some individuals who consider the dietary patterns described above too drastic a change can reduce their blood pressure just by lowering their salt intake. Those who adopt a DASH dietary pattern and reduce their salt intake can lower their blood pressure even more. All individuals should receive advice to limit their salt intake and be counseled on ways to do so.

Cholesterol

Despite much public attention given to cholesterol in the diet as a cause of poor health, there has been very little research on the effect of reducing dietary cholesterol on the risk of future disease. Therefore, no recommendation can be made to counsel individuals specifically on dietary cholesterol intake.

Physical Activity

Regular aerobic physical activity (e.g., walking, jogging, dancing, swimming, water-walking, gardening, climbing stairs and even house cleaning) and resistance training (e.g., working with light weights or elastic bands) can reduce the risk of serious disease by lowering LDL cholesterol and blood pressure. Individuals should be encouraged to engage in at least 30 minutes of an activity they enjoy, suitable to their current health status and risk, at least three times a week with no more than two consecutive inactive days. More intensive physical activity (e.g., up to 60 minutes at a setting, more sessions per week), for those whose health status permits, offer more benefit.

 

12410 References and Information

Revision 19-0; Effective July 1, 2019

 

Reference

National Heart, Lung and Blood Institute. Lifestyle interventions to reduce cardiovascular risk: Systematic Evidence Review from the Lifestyle Work Group (2013). Available at http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/lifestyle.

Information for Patients and Educators

American Heart Association, Healthy Eating. Provides information on food choices, recipes, how to eat healthy when dining out and how to shop for groceries with a focus on healthy eating. Available at http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Healthy-Eating_UCM_001188_SubHomePage.jsp.

American Heart Association, Get moving! Easy tips to get active. Provides information on physical activity and fitness. Available at http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/Physical-Activity_UCM_001080_SubHomePage.jsp.

American Heart Association, Sodium and Salt. Provides information on ways to reduce dietary salt intake. Available at http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/Sodium-and-Salt_UCM_303290_Article.jsp#.WThZ4-v1DRY.

Mayo Clinic, Healthy diets. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/basics/healthy-diets/hlv-20049477.

Mayo Clinic, DASH diet: Healthy eating to lower your blood pressure. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/dash-diet/art-20048456.

Mayo Clinic, DASH diet recipes. Available at http://www.mayoclinic.org/healthy-lifestyle/recipes/dash-diet-recipes/rcs-20077146.

Mayo Clinic, Mediterranean diet recipes. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet-recipes/art-20046682.

 

12500 Perinatal Clinical Policy

Revision 19-0; Effective July 1, 2019

 

Prenatal services should be provided based on American College of Obstetricians and Gynecologists (ACOG) guidelines.

Components of Initial Prenatal Interventions/Screening

Prenatal Visit – The initial encounter with a pregnant woman includes a complete history, physical examination, assessment, planning, treatment, counseling and education (referral as indicated), routine prenatal laboratory tests and additional laboratory tests as indicated by history, physical exam and/or assessment.

Components of Return Visit Interventions/Screening

Return Prenatal Visit – The follow-up prenatal visit includes interval history, physical examination, risk assessment, medical services, nutritional counseling, psychosocial counseling, family planning counseling and client education regarding maternal and child health topics. Hemoglobin and/or hematocrit, and urinalysis for protein and glucose are also included.

 

12510 Perinatal Histories

Revision 19-0; Effective July 1, 2019

 

Prenatal Visit

The comprehensive medical history documented at the initial prenatal visit must
at least address the following:

Return Prenatal Visits

The interval history includes:

 

12520 Physical Assessments

Revision 19-0; Effective July 1, 2019

 

All initial and routine prenatal visits must include an appropriate physical exam according to the purpose of visit and week of gestation. For any portion of the examination that is deferred, the reason(s) for deferral must be documented in the client health record.

Initial Prenatal Visit

Return Prenatal Visits

 

12530 Laboratory and Diagnostic Tests

Revision 19-0; Effective July 1, 2019

 

All initial and return prenatal visits must include appropriate laboratory and diagnostic tests, as indicated by weeks of gestation and clinical assessment. Contractors must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

Initial Prenatal Visit Laboratory and Diagnostic Tests

Review CDC’s revised recommendations for HIV testing for adults and pregnant women:

 

12531 ACOG/ACS/ASCCP/ASCP Cervical Cancer Screening Guidelines 

Revision 19-0; Effective July 1, 2019

 

Women with special circumstances, who are considered high-risk [e.g. HIV positive, immunosuppressed or were exposed to Diethylstilbestrol (DES) in utero] may be screened more frequently as determined by the clinician.

Individuals already following a plan of care/algorithm may continue with that plan of care/algorithm until completed and they return to routine screening. Once the person returns to routine screening, follow the guidelines above.

 

12532 Return Prenatal Visits Laboratory and Diagnostic Tests

Revision 19-0; Effective July 1, 2019

 

 

12533 Ultrasounds

Revision 19-0; Effective July 1, 2019

 

Obstetrical ultrasounds will be reimbursed when clinically indicated, including the
following:

Complete ultrasound – A complete evaluation of the pregnant uterus, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Complete ultrasound for confirmed multiple gestation – A complete evaluation of the pregnant uterus that includes viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Follow-up or limited ultrasound – A brief, more limited evaluation of the pregnant uterus that may follow a previous complete exam, be it an initial exam prior to 12 weeks or an initial exam at 12 weeks which is limited in scope. It includes fetal number, viability, presentation, dating measurements, limited anatomic assessment, placental localization and characterization, and amniotic fluid assessment.

 

12534 Repeat D Antibody Test

Revision 19-0; Effective July 1, 2019

 

For all unsensitized D-negative women at 24 through 28 weeks of gestation, followed by the administration of a full dose of D immunoglobulin if they are antibody negative. If the father is known with certainty to be Rh D-negative, this may be deferred.

 

12535 Special Procedures

Revision 19-0; Effective July 1, 2019

 

Nonstress test (NST) – Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider deems the procedure to be medically necessary.

Biophysical Profile (BPP)/Fetal Biophysical Profile (FBPP) – Fetal well-being
assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider deems the procedure to be medically necessary.

 

12540 Education and Counseling Services

Revision 19-0; Effective July 1, 2019

 

Contractors must have written plans for individual education that ensure consistency and accuracy of information provided, and that identify mechanisms used to ensure client understanding of the information.

Education and counseling must be:

Education and counseling during the initial prenatal visit, based on health history, risk assessment and physical exam, must cover the following:

Education and counseling during the return prenatal visits, should be appropriate to weeks’ gestation and be based on health history, risk assessment and physical exam, including but not limited to:

Tobacco Assessment and Quit Line Referral – All women receiving prenatal services should be assessed for tobacco use. Women who use tobacco should be referred to tobacco quit lines. The Texas American Cancer Society Quit Line is 877-YES-QUIT or 866-228-4327 (hearing impaired). The assessment and referral should be performed by agency staff and documented in the clinical record.

Information for Parents of Newborns Requirement Chapter 161, Health and Safety Code, Subchapter T, requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery, to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource pamphlet that includes information on postpartum depression, shaken baby syndrome, immunizations, newborn screening, pertussis and sudden infant death syndrome. In addition, it must be documented in the person's chart that she received this information and the documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery.

Information for Parents of Children Chapter 161, Health and Safety Code,
Subchapter T, also requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid, to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource guide that includes information relating to the development, health and safety of a child from birth until age five. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate child care.

Provision of Information about Umbilical Cord Blood Donation Requirement Chapter 162, Health and Safety Code, Subtitle H, requires that a physician, or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant, shall provide the woman with an informational brochure before the third trimester of the woman’s pregnancy or as soon as reasonably feasible, that includes information about the uses, risks and benefits of cord blood stem cells for a potential recipient, options for future use or storage of cord blood, the medical process used to collect cord blood, any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery and average cost of public and private storage. The brochure is available on the DSHS website or can be ordered from the DSHS literature warehouse. https://www.dshs.state.tx.us/pdf/umbilical_brochure_(2).pdf

Education and counseling during postpartum visits should include, but not be limited to:

 

12541 Referral and Follow-up

Revision 19-0; Effective July 1, 2019

 

Agencies must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to patients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information.

For services determined to be necessary, but which are beyond the scope of the agency, patients must be referred to other providers for care. (Whenever possible, patients should be given a choice of providers from which to select.) When a patient is referred to another provider, or for emergency clinical care, the agency must: