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Prenatal Care Coordination Services Handbook
Appendix 4

Medicaid-Allowable Procedure Codes and Modifiers for Prenatal Care Coordination Services

Procedure Codes

Procedure Description
W7090 Risk Assessment (See modifiers below)*
W7091 Initial Care Plan Development*
W7092 Ongoing Care Coordination and Monitoring*
W7093 Health Education /Nutrition Counseling - Individual*
W7094 Health Education/Nutrition Counseling - Group*

Risk Assessment (Pregnancy Questionnaire) Score Modifier

The risk assessment (Pregnancy Questionnaire [PDF, 119 KB]) must be billed using the appropriate two-digit modifier to indicate the recipient’s total risk assessment score. Claims for risk assessments that are submitted without a modifier are denied. The modifiers in the gray cells represent modifiers for recipients who do not qualify for prenatal care coordination (PNCC) services. Providers do not need to use modifiers with other PNCC procedure codes, except as noted below.

Score Modifier Score Modifier Score Modifier Score Modifier
00-09 00 80-89 08 160-169 16 240-249 24
10-19 01 90-99 09 170-179 17 250-259 25
20-29 02 100-109 10 180-189 18 260-269 26
30-39 03 110-119 11 190-199 19 270-279 27
40-49 04 120-129 12 200-209 20 280-289 28
50-59 05 130-139 13 210-219 21 290-299 29
60-69 06 140-149 14 220-229 22 300 or greater 30
70-79 07 150-159 15 230-239 23

*Subsequent Pregnancy (SP) Modifier

When billing for services provided within 185 days of a previous pregnancy, all procedure codes require the modifier "SP" (for example, when billing for a care plan for a subsequent pregnancy, procedure code W7091 requires the modifier "SP" if the date of service is within 185 days of the first care plan). When billing for the second risk assessment (Pregnancy Questionnaire), the modifier representing the risk assessment score must also be used.

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