Wiki Insight on billing 59425 and 59426 codes.

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baskiles

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Local Chapter Officer
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Smyrna, TN
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We are having issues with insurance carriers paying for our 59425 and 59426 codes. Carriers often deny because of timely filing as we put a from date (the date the patient started their care with us) with a to date (the last date the patient saw us for their antepartum care). It seems the payer picks up on the first date which is the from date and of course it's greater than 120 days and they deny timely filing. How do you bill your antepartum only - can you offer me resources. We are in TN and have the hardest time with our MCO Wellpoint. Also, how many antepartum visits do you consider for OB global billing when you do the delivery and post partum care? Most policies say "about 13". Someone said ACOG say 7--. Any resources you can provide on any of these questions would be appreciated?
 
From my experience, anytime a carrier accepts global maternity billing, it can be a challenge when billing needs to be split. If you provided some/all antepartum care, but did not deliver, then 59425 or 59426 could be appropriate. However, if another provider also billed for global, or a portion of the antepartum care, it will typically be denied for overlapping services and may require appeal. A denial does not mean you billed incorrectly. I don't think I've had issues with timely when needing to split bill.
The key question is **Did your practice provide all antepartum, delivery & postpartum care?**
If yes, and there were at least 7 antepartum visits, I would bill global
If yes, and there were 4-6 antepartum visits, I would split bill for 59425 and then delivery plus postpartum.
If yes, and there were 1-3 anteparttum visits, each visit is billed as an E&M and then delivery plus postpartum
If no, regardless of the number of antepartum visits, I split bill.
In the event the payor has a policy contrary to my general guidance, I follow the payor policy.
You specifically mention TN Wellpoint. Here is their policy which seems to follow my general guidance:
 
Also, are your payers requiring a "to/from" date? The only payer for which we add those are UHC payers. If they're not, you might want to consider leaving them off.
 
csperoni said:
From my experience, anytime a carrier accepts global maternity billing, it can be a challenge when billing needs to be split. If you provided some/all antepartum care, but did not deliver, then 59425 or 59426 could be appropriate. However, if another provider also billed for global, or a portion of the antepartum care, it will typically be denied for overlapping services and may require appeal. A denial does not mean you billed incorrectly. I don't think I've had issues with timely when needing to split bill.
The key question is **Did your practice provide all antepartum, delivery & postpartum care?**
If yes, and there were at least 7 antepartum visits, I would bill global
If yes, and there were 4-6 antepartum visits, I would split bill for 59425 and then delivery plus postpartum.
If yes, and there were 1-3 anteparttum visits, each visit is billed as an E&M and then delivery plus postpartum
If no, regardless of the number of antepartum visits, I split bill.
In the event the payor has a policy contrary to my general guidance, I follow the payor policy.
You specifically mention TN Wellpoint. Here is their policy which seems to follow my general guidance:
Click to expand...
Thank you- This information has been very helpful. I have a follow up question if you don't mind. Do you know if Wellpoint TN is requiring a to and from date when using antepartum only codes 59425 or 59426 when we didn't provide delivery? We have been adding to and from dates and I really feel like that is the issue. Again, thank you! I really like to stay connected.
 
Cmama12 said:
Also, are your payers requiring a "to/from" date? The only payer for which we add those are UHC payers. If they're not, you might want to consider leaving them off.
Click to expand...
Yes, UHC requires it- Blue Care allows it but I'm thinking Wellpoint TN doesn't like it at all. I feel this may be our issue. Thank you!
 
baskiles said:
Thank you- This information has been very helpful. I have a follow up question if you don't mind. Do you know if Wellpoint TN is requiring a to and from date when using antepartum only codes 59425 or 59426 when we didn't provide delivery? We have been adding to and from dates and I really feel like that is the issue. Again, thank you! I really like to stay connected.
Click to expand...
You can check their policy more carefully than I did, but at a glance I did not see this required. I'm in NY and have zero experience with Wellpoint TN.
I know for our carriers, we typically bill out the 59425/59426 with the date of last treatment, not a range.
 
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