Effective August 28, 2018, a significant update was implemented regarding the Coding Antepartum Care policy, especially when multiple provider groups are involved in a pregnant patient’s care. This change addresses scenarios where different provider groups render portions of the antepartum care. Under the revised policy, it’s no longer appropriate for the delivering physician to bill using a global obstetrical delivery code if they haven’t provided the entirety of the antepartum care. This adjustment ensures accurate billing and reflects the shared responsibility in patient care across different providers.
Instead of global delivery codes, delivering physicians are now directed to use either the delivery only code or the delivery only code that includes postpartum care. This coding adjustment is made in addition to billing for the specific portion of antepartum care they provided, when applicable, using CPT codes 59425 or 59426. Claims submitted with global delivery codes by providers who did not render all of the antepartum care will face denial due to inappropriate coding.
Antepartum Billing Guidelines Based on Visit Number
To clarify the correct coding antepartum care, specific guidelines are provided based on the number of antepartum visits conducted by a provider group:
- For 1 to 3 visits: Providers should utilize evaluation and management (E/M) office visit codes to bill for these initial, fewer visits.
- For 4 to 6 visits: CPT code 59425 becomes the appropriate code. It’s crucial to note that CPT code 59425 should not be billed by the same provider group alongside 1 to 3 office visits, or in conjunction with CPT code 59426 to prevent coding errors and claim denials.
- For 7 or more visits: CPT code 59426 should be used. It’s important to understand that complete antepartum care, coded under 59426, is limited to one beneficiary pregnancy per provider group, ensuring accurate and non-duplicative billing practices.
Coding for Antepartum Services Only
In situations where a physician or provider group exclusively provides antepartum services and does not handle the delivery, the coding antepartum care process is as follows:
- Utilize CPT code 59426 if 7 or more antepartum visits are provided.
- Employ CPT code 59425 if the service encompasses 4 to 6 antepartum visits.
- For scenarios involving only 1 to 3 visits, an evaluation/management visit code should be used for each individual visit, accurately reflecting the service provided.
Alignment with ACOG and AMA Guidelines
These coding antepartum care guidelines are in direct accordance with the established recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA). For antepartum care only codes 59425 or 59426, the guidelines from ACOG and AMA emphasize:
- Reporting a single claim submission for CPT code 59425 or 59426 for the entirety of antepartum care provided, excluding the initial confirmation visit (which can be reported and reimbursed separately if the antepartum record isn’t yet initiated).
- Reporting units should be set to one, representing a single episode of antepartum care within the specified visit range.
- The dates reported should reflect the range of time during which the services were rendered. For example, if a patient received 4-6 antepartum visits, CPT code 59425 should be reported with the “from” and “to” dates spanning the period of service.
This updated policy and these guidelines are put in place to ensure correct coding antepartum care practices, reflecting the collaborative nature of modern obstetric care and aligning with national standards set by ACOG and AMA. Adherence to these guidelines is crucial for accurate billing and reimbursement in obstetric services.
