High Risk Prenatal Home Care
will be covered if indicated and when ordered by a network Maternal-Fetal
Medicine (Perinatology) provider.
eligible for High Risk Prenatal Home Care coverage, such care must be
recommended after consultation with a Maternal-Fetal Medicine specialist, and
one of the following must be present:
of previous pre-term labor or delivery (O09.211 – O09.219, Z87.51) OR
multiple gestation pregnancy (O30.001 – O30.019, O30.031 – O31.8X99)
from current pregnancy (O20.0 – O20.9, O26.851 – O26.859, O44.00 –
O46.93, O67.0 – O67.9) OR
complications of current pregnancy, including (but not limited to):
Pyelonephritis (O23.00 – O23.03)
Placenta Previa (O44.00 – O44.13)
Polyhydramnios (O40.1XX0 – O40.9XX9)
Premature labor (O60.00 – O60.23X9)
monitored home care for a high risk OB patient will be based on the need for
skilled prenatal nursing knowledge and skills. Examples of skilled prenatal
nursing care may include (but are not limited to):
for the member to understand the importance of adherence to prenatal medical
protocol (bed rest, hydration, reinforcement of oral tocolytic schedule).
for the member in identification and timing of uterine contractions,
symptoms that may indicate signs of pre-term labor (abdominal cramping, low
back pain, changes in character or amount of vaginal discharge, vaginal
pressure, etc). A teaching flow sheet should be used for this education,
and be kept with the clinical record.
palpation and documentation of uterine activity.
assessment and documentation of cervical changes and the timing of uterine
Administration and monitoring of intravenous or subcutaneous tocolytic
of skilled nursing assessments in the member’s medical record and
communication of any changes to the physician responsible for the prenatal
Home uterine monitoring using
shall be provided for the pre-term use of ambulatory tocodynamometers (uterine
contraction devices) and for any home-care service when the next steps in care
are determined primarily based on information obtained by such a device or
will be given to coverage of local hotel (or hostel) stay when care in a
transient O/P status is in lieu of inpatient care for a non-Pulaski County
therapy is not recommended in patients prior to twenty weeks gestation.
will terminate if member is not compliant with treatment requirements in the
Hospitalization is recommended when patients are experiencing progressive
pre-term labor symptoms with no response to the home care treatment plan that is
ordered by the attending Maternal-Fetal Medicine specialist.