Coding Antepartum Care by Different Provider Groups

Date Issued: 5/23/2018

Starting on August 28, 2018, we’re changing our coding policy for antepartum care by different provider groups. When more than one provider group renders a portion of the antepartum care to a pregnant member, it is inappropriate for the delivering physician to bill with a global obstetrical delivery code. Instead, the delivering physician should bill either the delivery only code or the delivery only code that includes postpartum care. This is in addition to the portion of the antepartum care (CPT codes 59425 or 59426) provided, if applicable. Global delivery codes billed by a provider who did not render all of the antepartum care will be denied as inappropriately coded services.

Antepartum billing guidelines:

  • For 1 to 3 visits: Use evaluation/management (E/M) office visit codes.
  • For 4 to 6 visits: Use CPT code 59425. This code must not be billed by the same provider group in conjunction with 1 to 3 office visits, or in conjunction with CPT code 59426.
  • For 7 or more visits: Use CPT code 59426 – Complete antepartum care is limited to one beneficiary pregnancy per provider group.

If the patient is treated for antepartum services only, the physician should use:

  • CPT code 59426 if 7 or more visits are provided.
  • CPT code 59425 if 4-6 visits are provided.
  • An evaluation/management visit code for each visit if only providing 1-3 visits.

The following are guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA) for antepartum care only code 59425 or 59426:

  • Report a single claim submission of CPT code 59425 or 59426 for the antepartum care only, excluding the confirmation visit that may be reported and separately reimbursed when the antepartum record has not been initiated.
  • The units reported should be one.
  • The dates reported should be the range of time covered. For example, if the patient had a total of 4-6 antepartum visits, the physician/group should report CPT code 59425 with the “from” and “to” dates when services were rendered.

This new policy is in accordance with the American College of Obstetricians and Gynecologists and the American Medical Association CPT coding guidelines for obstetric services.