Coding, Classification and Reimbursement

CPT 59425

  • 1.  CPT 59425

    Posted 19 days ago
    Hello. I'm Steve a medical coder for a community health center. I was wondering if anyone knows how to code the CPT 59425 for antepartuem care. I know you can use the code only once for visits 4-6 and have to write the "to" and "from" date. It seems like there should be a code for visits 4 and 5. The issue I am having is the providers code 59425 for visits 4,5,6 and two of them get rejected. It seems like you would lose money if you have to bunch the 3 visits into one code. Any help would be appreciated. Thanks

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    Steve Oehmen
    Medical coder
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  • 2.  RE: CPT 59425

    Posted 18 days ago
    It's a bundled code, meaning one code is priced to cover all 3 visits.  The FROM date should be visit 4 and the TO date is visit 6. If you're billing the code separately for each visit, that's why 3 of them get rejected. Perhaps you need to look at how you price this code to be sure it covers 3 visits. 

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  • 3.  RE: CPT 59425

    Posted 18 days ago
    Thank you for the reply. Yes that's the way it reads to me too, but I have found examples of Medicaid and other insurances paying for each visit with the 59425 and others rejecting it stating that you can only use the code once. Is that more of an example of the insurance company rep not knowing the code. The 59425 really doesn't pay that much. In Indiana it is only $72 and that has to cover 3 visits.

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    Steve Oehmen
    Medical records clerk
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  • 4.  RE: CPT 59425

    Posted 18 days ago
    Hi Steve-

    In order to answer your question, more information is needed.  Do these women come to your clinic only for prenatal care or do your providers also do the delivery and postpartum care?  If your providers are doing all of the prenatal care but not the delivery, or postpartum, you would be billing 59426 instead of 59425.

    Usually, the OB billing is not done until after delivery so the coder can determine if the requirements for a complete OB package are met or if they need to split out the components.

    For your place of service, maybe it is common to have women come for a few OB visits but deliver somewhere else with a different provider group?  Let me know if this is correct.

    As to your general question about 59425 - it is meant to be a mini package - the provider receives a higher RVU and higher fee schedule amount because it involves more work than a single visit.

    -Katie



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    Kathryn O'Hearn, RHIA, CCS-P, CRC
    Provider Education Program Manager
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  • 5.  RE: CPT 59425

    Posted 16 days ago
    Thank you for your reply. Its a community health center and we mostly provide prenatal care and maybe some after the delivery. We don't provide delivery services at all. Yes you are correct about women coming for OB visits than at a fixed month into their pregnancy we refer them out to another provider.
    I seem to understand its a mini-package, but we code the 59425 and basically get $72 for the code whereas we normally get $100 per regular office visit. Is it possible that the amount we have for the code is wrong and the insurance companies are not going to say "No, we have to pay you more for their service" we have had issues with some codes not even having charges attached to the code. Thanks

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    Steve Oehmen
    Medical records clerk
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  • 6.  RE: CPT 59425

    Posted 16 days ago
    Thanks everyone for the help. I was able to find the code in our software that has the fee for the 3 visits as $450 which seems to be the right amount. I no longer have any more questions about this code.

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    Steve Oehmen
    Medical records clerk
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  • 7.  RE: CPT 59425

    Posted 2 days ago
    I have a follow up question. What if the patient only comes for example visit 4 to our office than visit 5 and 6 somewhere else. How do you code for less than the 3 visits? Also are these visits basically a once a month visit or if they come in 3 weeks in a row for a antepartuem do you code the 59425 package and code 59426 on the next visit and if there is a 8th or more visits how do you code that? Thank you. This is a whole big issue at my workplace because we are a FQHC and they basically have not been coding this right

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    Steve Oehmen
    Medical Records Clerk
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  • 8.  RE: CPT 59425

    Posted 2 days ago

    1-3 antepartum visits are billed with the appropriate E/M code. This instruction appears before code 59425 int eh CPT manual.

    "(For antepartum care only, see 59425, 59426 or appropriate E/M code[s])"

    "(For 1-3 antepartum care visits, see appropriate E/M code[s])"

    4, 5, or 6 visits are billed with code 59425
    7 or more visits are billed with code 59426.

    This refers to the total number of visits, not each individual visit, e.g. not the "seventh" visit. If a patient has seven or more visits, you bill only 59426. Do not bill 59425 for 6 visits and 59426 for the 7th visit.
    I hope that helps.

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