2026 Quality HEDIS Provider PPC Flyer
Date: 06/11/26
Prenatal and Postpartum Care (PPC)
Why it Matters
Each year, one million of the roughly four million women giving birth in the U.S. experience complications during pregnancy, labor and delivery, or postpartum. Studies indicate that as many as 60% of all pregnancy-related deaths could be prevented if women had better access to high-quality healthcare and made changes in their health and lifestyle habits. Timely and adequate prenatal and postpartum care can set the stage for the long-term health and wellbeing of new mothers and their infants.
Eligible Population
Members who have a live birth delivery on or between Oct. 8 of the year prior to the measurement year and Oct. 7 of the measurement year.
Measure Description
For the eligible population, the measure assesses the following:
- Timeliness of prenatal care: The percentage of deliveries that received a prenatal care visit in the first trimester on or before the enrollment start date, or within 42 days of enrollment in the health plan.
- Postpartum care: The percentage of deliveries that had a postpartum visit between 7 and 84 days after delivery.
Key Tips
- Services provided during a telephone visit, e-visit or virtual check-in are eligible for use in reporting. For members who do not show or schedule appointments, attempt to engage in a telephone or video visit to close gap.
- Identify members seen in ER with a diagnosis of pregnancy and initiate follow-up.
- Maintain available appointments for the member to be seen during their first trimester or postpartum period. Use appropriate CPT Category II codes for pregnancy diagnosis office visits and postpartum visits when submitting claims for bundle maternity services. CPT Category II helps identify clinical outcomes and can reduce the need for some chart review.
Prenatal Care Documentation
Acceptable documentation with visit date and evidence of one of the following:
· A diagnosis of pregnancy (this must be included for PCP visits). Example: Visit to confirm pregnancy.
· Documentation indicating the member is pregnant or references to the pregnancy.
Examples:
· Standardized prenatal flow sheet.
· Documentation of LMP, EDD, gestational age or gravidity and parity.
· Notation of positive pregnancy test result.
· Documentation of complete OB history.
· Documentation of prenatal risk assessment and counseling.
A basic physical obstetric examination with auscultation for fetal heart tone, pelvic exam, obstetric
observations or measurement of fundus height.
Evidence that a prenatal care procedure was performed.
Examples:
· Screening test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing).
o TORCH antibody panel.
o Rubella antibody test/titer with RH incompatibility (ABO/Rh) blood typing.
o Ultrasound of a pregnant uterus.
Not Acceptable Documentation:
· Ultrasound and lab results not combined with an office visit.
· A visit or documentation with a RN alone (visit must be associated with appropriate provider’s note).
· A Pap test.
Postpartum Care Documentation
Acceptable documentation with visit date and evidence of one of the following:
· Notation of postpartum care, including, but not limited to:
o Notation of “Postpartum care,” “PP care,” “PP check,” “6-week check”.
· Evaluation of weight, BP, breasts and abdomen.
o Notation of “breast feeding” is acceptable for evaluation of breasts.
· Perineal or cesarean incision/wound check.
· Screening for depression, anxiety, tobacco use, substance use disorder or preexisting mental health disorders.
· Pelvic exam: a Pap test is acceptable as evidence of a pelvic exam.
· Glucose screening for members with gestational diabetes.
· Documentation of discussion of any of the following topics:
o Infant care / breastfeeding.
o Resumption of intercourse, birth spacing or family planning.
o Sleep or fatigue.
o Resumption of physical activity.
o Attainment of healthy weight.
Not Acceptable Documentation:
· Colposcopy alone.
· Care in an acute inpatient setting.
Measure Codes
Acceptable documentation with visit date and evidence of one of the following:
· A diagnosis of pregnancy (this must be included for PCP visits). Example: Visit to confirm pregnancy.
· Documentation indicating the member is pregnant or references to the pregnancy.
Examples:
o Standardized prenatal flow sheet.
o Documentation of LMP, EDD, gestational age or gravidity and parity.
o Notation of positive pregnancy test result.
o Documentation of complete OB history.
o Documentation of prenatal risk assessment and counseling.
· A basic physical obstetric examination with auscultation for fetal heart tone, pelvic exam, obstetric observations or measurement of fundus height.
· Evidence that a prenatal care procedure was performed.
Examples:
o Screening test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing).
o TORCH antibody panel.
o Rubella antibody test/titer with RH incompatibility (ABO/Rh) blood typing.
o Ultrasound of a pregnant
Not Acceptable Documentation:
• Ultrasound and lab results not combined with an office visit.
• A visit or documentation with a RN alone (visit must be associated with appropriate provider’s note).
• A Pap test.
Postpartum Care Documentation
Acceptable documentation with visit date and evidence of one of the following:
· Notation of postpartum care, including, but not limited to:
o Notation of “Postpartum care,” “PP care,” “PP check,” “6-week check”.
· Evaluation of weight, BP, breasts and abdomen.
o Notation of “breast feeding” is acceptable for evaluation of breasts.
· Perineal or cesarean incision/wound check.
· Screening for depression, anxiety, tobacco use, substance use disorder or preexisting mental health disorders.
· Pelvic exam: a Pap test is acceptable as evidence of a pelvic exam.
· Glucose screening for members with gestational diabetes.
· Documentation of discussion of any of the following topics:
o Infant care / breastfeeding.
o Resumption of intercourse, birth spacing or family planning.
o Sleep or fatigue.
o Resumption of physical activity.
o Attainment of healthy weight.
Not Acceptable Documentation:
· Colposcopy alone.
· Care in an acute inpatient setting.
Measure Codes
Prenatal | Codes |
Prenatal bundled services (may only be used if the claim form indicated when prenatal care was initiated) | CPT: 59400, 59425, 59426, 59510, 59610, 59618 HCPCS: H1005 |
Standalone prenatal visits | CPT/ CPT II: 99500, 0500F–0502F HCPCS: H1000–H1004 |
Prenatal visits (must include a pregnancy-related diagnosis code) | CPT: 98000–98016, 98966–98968, 98970–98972, 98979, 98980, 98981, 99202–99205, 99211–99215, 99242–99245, 99421–99423, 99441–99443, 99457, 99458, 99470, 99483 HCPCS: G0071, G0463, G0544, G2010, G2012, G2250–G2252, T1015 Note: T1015 identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC). |
Prenatal | Codes |
Postpartum visits | CPT / CPT II: 57170, 58300, 59430, 99501, 0503F HCPCS: G0101 |
Postpartum bundled services (may only be used if the claim form indicates when postpartum care was rendered) | CPT: 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622 |
Cervical cytology | CPT: 88141–88143, 88147, 88148, 88150, 88152, 88153, 88164–88167, 88174, 88175 HCPCS: G0123, G0124, G0141, G0143–G0145, G0147, G0148, P3000, P3001 |