Are you an obstetrician struggling to get paid for antepartum care visits since the patient moved out of the practice or miscarried? If you are billing the global code 59400 that covers everything from prenatal care to labor management and delivery to postpartum care, then the denials are understandable.
Because there are mini global service codes, such as CPT code 59426. Before we get into the details of this code, here’s a golden rule you should always follow! If you have not rendered all the services covered under a global package, then look for a mini global code, or another code that most precisely matches the performed services.
CPT Code 59426 – Description
CPT code 59426 covers seven or more antepartum encounters. It is a mini global code that identifies a reduced service portion of the global code 59400.
Here’s how it works! There may be circumstances that lead to the patient transferring out of the practice before delivery or the pregnancy terminating before delivery. In such cases, the OBGYN does not perform all of the antepartum care. However, he may perform the delivery with or without postpartum care when the patient transfers in from another practice.
When any of these scenarios occur, you cannot report the global code 59400.
Scenarios Where CPT Code 59426 is Applicable
Reviewing the following real-world clinical scenarios will help you better understand where CPT 59426 applies:
Patient Transfers Out Prior to Delivery
Picture an OBGYN (Dr.John) who rendered comprehensive prenatal care to a patient for the majority of her pregnancy. The documentation supports a total of ten routine antepartum visits from week 8 through week 35.
However, the patient has to relocate immediately to a different city due to a job change. As a result, her care is transferred to a new obstetrician (Dr. Sarah) for the remainder of the pregnancy and delivery.
Here, Dr. John will report CPT code 59426 to bill for the ten antepartum encounters since he cannot use CPT code 59400. The reason? He did not perform the delivery or postpartum care.
Pregnancy Terminates Mid-Third Trimester
Assume a scenario where a patient received routine prenatal care from an obstetrician for 29 weeks of pregnancy. This accumulates to eight encounters. But, unfortunately, at 29 weeks, the patient experiences a spontaneous miscarriage.
Therefore, the obstetrician performed an emergency D&C that is billed separately. In this scenario, the obstetrician cannot report CPT code 59400 since the patient did not receive delivery service or postpartum care. Here, CPT code 59426 is applicable for billing the antepartum visits.
Emergency Delivery After 7 Visits
Imagine a patient who has been receiving regular prenatal care from the obstetrician. So far, she has visited the clinic seven times for antepartum care. But at 26 weeks, she developed severe pre-eclampsia, necessitating labor induction and delivery for maternal safety. Thus, another obstetrician performed the emergency delivery.
Now, here’s how you should code the service. Report CPT code 59426 to bill for the prenatal encounters. Additionally, for the delivery service, you must use a relevant delivery code.
CPT Code 59426 – Billing & Reimbursement Guidelines
Master the reimbursement requirements for antepartum care visits and ensure a steady cash flow:
Fulfill Documentation Requirements
Your documentation acts as the key to ensuring payment for your rendered services. Thus, it must be detailed and accurate. Here’s what it must include:
- Clearly state that the patient visited you at least seven times for distinct, routine, in-person antepartum care encounters.
- Mention the specifics of the routine prenatal visits, e.g., mother’s health assessment, fetal heart tone check, etc.
- Describe the reason for billing the mini global code. That is, the patient moved out, pregnancy terminated, etc.
Do Not Report CPT Code 59426 For Less Than 7 Visits
In cases where the obstetrician rendered fewer than seven antepartum visits, avoid reporting CPT 59426. But why? There is another, more specific code available, i.e., CPT code 59425. You can report this code to bill four to six encounters.
Do Not Use Modifier 52 with CPT 59426
For context, modifier 52 highlights that the service was reduced at the physician’s discretion. However, CPT code 59426 already defines a reduced portion of the global package covered under CPT 59400. Therefore, there is no need to append modifier 52 while reporting it.
Report E/M Services Separately
CPT code 59426 covers only routine prenatal visits. Therefore, if the patient encounter was solely for problem management, such as urinary tract infection (UTI) treatment, bill those visits separately with appropriate evaluation and management (E/M) codes.
Summary
We often emphasize that medical billing requires attention to detail for billing each procedure. Sometimes, the use of modifier 52 becomes integral to ensure you do not overbill. However, other times you simply do not need a modifier because we already have a reduced service code. The same applies to CPT code 59426!
It is a mini global service code that covers seven or more antepartum visits, without delivery and postpartum care. You use it when you cannot bill 59400 since the patient moved out of the practice or the pregnancy was terminated before delivery.
Hopefully, this guide will help you accurately code for your prenatal patient encounters. However, if you still struggle, feel free to outsource OBGYN billing services to MediBillMD.
