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CPT Code 59426 Guide to Billing Antepartum Care Services

Name: Cures Medical Billing Services Company
Address: 3811 Ditmars Blvd# 1124, Astoria, NY 11105, Astoria, NY, 11105, USA
Telephone: +1 (917) 994-9941

What is CPT Code 59426?

CPT code 59426, maintain by the American Medical Association (AMA), is a “mini global code” used for antepartum care only. This code applies to healthcare providers who deliver seven or more antepartum visits but do not perform the complete vaginal delivery, postpartum care, or both.

Properly understanding and correctly applying this code are essential for accurate medical billing and reimbursement.

When to Use CPT Code 59426?

CPT 59426 is used in scenarios where a provider offers antepartum care but does not manage the entire maternity care package. Common situations where this code is applicable include:

The patient transfers out of the practice before delivery.
The pregnancy ends before delivery.
The provider offers antepartum care but does not perform the actual delivery.

It is important to note that complete antepartum care is limited to one beneficiary pregnancy per provider group. If multiple providers in the same group see the patient, billing must be coordinated accordingly.

Key Considerations for Billing CPT Code 59426

Antepartum Care Only: CPT 59426 is specifically designated for antepartum services. It does not include labor, delivery, or postpartum care.
Number of Visits: This code applies to patients receiving seven or more antepartum visits. If fewer visits are provided, different codes must be used:
- CPT 59425: Used for 4-6 antepartum visits.
- Evaluation & Management (E/M) Codes: Used for 1-3 antepartum visits.
Global OB Care Package Exclusions: If a provider manages the entire obstetric care cycle, including antepartum, delivery, and postpartum services, different codes should be billed, such as:
- CPT 59400: Complete vaginal delivery package (includes antepartum, delivery, and postpartum care).
- CPT 59510/59514: Used for cesarean deliveries, with 59510 covering the full maternity package and 59514 covering only the surgical procedure.
Accurate Documentation: To ensure compliance and smooth reimbursement, providers should maintain accurate records of patient encounters. Documenting the exact number of visits and care provided is critical.
Payer-Specific Guidelines: Insurance payers may have unique billing rules, particularly when processing antepartum claims that extend into a new year. Checking with specific payers, such as Care Source Ohio or Medicaid programs, can help avoid claim denials.

Challenges and Solutions in Billing CPT 59426

Billing Across Two Calendar Years: If antepartum care spans two separate years due to insurance changes or late patient entry, claims should be split accordingly.
Unbundling OB Global Packages: If a patient receives prenatal care from multiple providers or transfers care mid-pregnancy, unbundling the global OB package may be necessary. Providers must separate visits and ensure proper coding to prevent claim denials.
Insurance Reimbursement Issues: Some payers may inconsistently reimburse maternity claims. If a claim for CPT 59426 is denied, consider submitting an appeal with detailed documentation of services provided.

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Final Thoughts

Understanding CPT 59426 and its correct application is crucial for providers offering antepartum care. Proper documentation, adherence to payer-specific guidelines, and accurate claim submissions can streamline reimbursement and prevent revenue losses.

If you need further assistance with billing antepartum care services, consulting a professional medical billing service like Cures Medical Billing Services can help optimize your revenue cycle management.

Frequently Asked Questions (FAQs)
What CPT code is 59426?
For seven or more visits, apply CPT code 59426. This code covers complete antepartum care and is limited to one pregnancy per beneficiary per provider group.
What is the difference between CPT 59425 and 59426?
CPT 59425 is used for 4-6 antepartum visits, whereas CPT 59426 is for seven or more visits. Both codes apply to antepartum care only and exclude delivery and postpartum services.
Can CPT 59426 be billed along with a delivery code?
No, CPT 59426 is used when a provider does not manage the complete delivery process. If a provider also performs delivery, they must use a global OB package code instead.
How can providers avoid claim denials when billing CPT 59426?
To prevent denials, providers should:
- Confirm the correct number of visits before billing.
- Verify insurance policies and prior authorization requirements.
- Document services accurately, specifying the exact number of visits and care provided.
- Submit claims with appropriate modifiers if required by payers.

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