FAQs on CPT® 2027 Antepartum and Prenatal Care Coding
The new changes for CPT® 2027 will impact reporting of antepartum and prenatal services. Antepartum visits will report to the appropriate evaluation and management (E/M) code and not be able to be counted by traditional bundled reporting from January 1, 2027.
These changes include E/M selection, medical decision making (MDM), time-based coding, pregnancy-related diagnosis, and modifier TH requirements. This guide provides answers to frequently asked questions about CPT® 2027 antepartum care coding and offers insights into how OBGYN practices can prepare for accurate prenatal billing, documentation, and OBGYN billing and coding when submitting claims.
How Is Antepartum Care Reported Under the New CPT® 2027 Structure?
Beginning January 1, 2027, CPT® changes the way antepartum and prenatal care is reported. Under the new structure, antepartum care is reported per encounter using the appropriate evaluation and management (E/M) service based on the location where care is provided.
The applicable setting may include:
- Office
- Hospital
- Telehealth
Standard E/M coding rules apply to each encounter. The appropriate E/M service may be selected based on either Medical Decision Making (MDM) or total time on the date of the encounter.
What Does This Mean for Prenatal E/M Coding?
The new approach means that an OBGYN practice should evaluate each prenatal encounter based on the services provided during that specific visit. A single E/M level should not automatically be applied to every antepartum visit.
For each encounter, coding teams should consider:
- The services provided during the visit
- The problems addressed
- The data reviewed and analyzed
- The risk of patient management, when using MDM
- The total time spent on the date of the encounter, when using time
Accurate provider documentation will therefore be important for supporting CPT® 2027 antepartum care coding and the E/M level reported.
How Are Nonphysician QHP Services Reported?
Not every qualified healthcare professional (QHP) may report E/M services. When a nonphysician QHP provides a service that is not reported with an E/M code, the specific service and its applicable coding guidance should be followed.
Examples identified in the AMA guidance include:
- Genetic counseling
- Medical nutrition therapy
Do Antepartum and Fetal Invasive Procedure Codes Still Apply?
Yes. The new antepartum reporting structure does not eliminate maternity-related procedural codes.
Antepartum and fetal invasive service codes remain reportable, and some services have been relocated within the CPT code set. Practices should therefore distinguish between an antepartum E/M encounter and a service that has its own applicable procedural code.
Key Point for CPT® 2027 Antepartum Coding
The big shift is moving towards encounter-based reporting for antepartum care. All prenatal encounters should be coded based on the appropriate E/M coding guidelines, and should be supported by MDM or total time, as applicable.
To ensure prenatal services are coded as outlined in the new CPT® structure, updating EHR charge capture, provider documentation and coding workflows before January 1st, 2027 may be helpful for practices specializing in OBGYN.
What Date of Service Should Be Reported for CPT® 59425 or 59426?
When reporting an antepartum-only code such as CPT® 59425 or 59426, the service is reported after the required number of visits included in the code has been completed.
The date of service should be the date of the last antepartum encounter included in the reported code. In other words, the service is considered concluded when all visits represented by CPT® 59425 or 59426 have been provided.
How Should the Date of Service Be Determined?
For antepartum-only billing, practices should:
- Complete the number of visits represented by the applicable code.
- Identify the last antepartum encounter included in that code.
- Report the date of that final encounter as the date of service.
- Review the payer’s specific reporting requirements before submitting the claim.
Can Payer Requirements Change the Reporting Method?
Yes. Third-party payer requirements may vary. While a payer may require only the final encounter date on the claim, another payer may request additional information, such as a date range covering the first and last dates of service, particularly when supporting documentation is submitted.
So, it is recommended that OBGYN billing teams review payer-specific guidelines for antepartum billing and date-of-service reporting, instead of relying on a single method for reporting for all payers.
Key Takeaway
For CPT® 59425 and 59426, the AMA guidance identifies the last antepartum encounter included in the code as the date of service. However, payer-specific requirements should also be checked because documentation and date-range reporting requirements can differ.
How Can Payers Identify Pregnancy-Related Encounters in Claims?
For CPT® 2027 prenatal and antepartum billing, pregnancy-related encounters can be identified through the appropriate ICD-10-CM pregnancy diagnosis codes. Depending on the circumstances, this may include codes from the Z34- category or the O chapter.
Where applicable, practices should also consider HCPCS modifier TH, which identifies obstetrical treatment/services, including prenatal or postpartum services.
When preparing a maternity claim, coding teams should therefore ensure that:
- The diagnosis codes accurately reflect the pregnancy-related care provided.
- Applicable Z34- or O chapter codes are reported based on the documented condition.
- Modifier TH is used when applicable.
- Payer-specific claim requirements are reviewed before submission.
Accurate diagnosis and modifier reporting can help clearly identify the encounter as related to maternity care.
Will Antepartum Visit Intensity Vary Across Patients?
Yes. Under the CPT® 2027 antepartum care structure, prenatal visits will generally be reported individually using the appropriate E/M code. The E/M level is determined for each specific encounter based on the services provided during that visit.
The code may be selected using either:
- Medical Decision Making (MDM), or
- Total time on the date of the encounter
This means there is no single fixed E/M level that automatically applies to every antepartum visit for a patient throughout pregnancy.
For example, the level selected for one prenatal encounter may differ from another when the services, MDM, or total time differ. Coding teams should evaluate each visit independently and select the E/M service supported by the documentation for that particular encounter.
Key Point for OBGYN Coding
There are more encounter-specific changes to the prenatal E/M codes in the 2027 revisions. Practices should not set a fixed level of complexity for all antepartum visits, but rather consider the services offered during each individual visit.
How Is Pregnancy Considered When Determining E/M MDM Complexity?
For CPT® 2027 antepartum E/M coding, pregnancy itself can be considered a problem addressed when determining the number and complexity of problems for MDM. However, normal pregnancy should not simply be classified as an acute, uncomplicated illness.
The CPT® guidance referenced by the AMA explains that, although pregnancy is not an illness, it is a condition that may be reported as a problem addressed during an E/M encounter. For MDM purposes, pregnancy is considered to fit the category of a chronic illness with exacerbation, progression, or side effects of treatment, rather than an acute, uncomplicated illness.
How Should Pregnancy-Related Comorbidities Be Considered?
Conditions such as gestational diabetes, hypertension, obesity, or advanced maternal age should be considered based on how they affect the care provided during the specific encounter.
A diagnosis by itself does not automatically increase the E/M level. A comorbid condition should be considered when it is addressed during the encounter and affects the applicable E/M elements, such as:
- The amount or complexity of data reviewed and analyzed
- The risk associated with patient management
- The overall complexity of the problems addressed
Multiple lower-severity problems may also contribute to greater complexity when their interaction increases the risk associated with patient management.
Does Pregnancy Alone Determine the E/M Level?
No. The pregnancy classification discussed above applies specifically to the Number and Complexity of Problems Addressed element of MDM.
Complete E/M leveling requires consideration of all three MDM elements:
- Number and Complexity of Problems Addressed
- Amount and/or Complexity of Data to Be Reviewed and Analyzed
- Risk of Complications and/or Morbidity or Mortality of Patient Management
Therefore, OBGYN coders should not select an E/M level based solely on the fact that the patient is pregnant or has a particular pregnancy-related diagnosis.
What Does This Mean for 2027 Prenatal Coding?
With the shift to individual antepartum E/M reporting in 2027, providers and coding teams should evaluate the circumstances of each prenatal encounter. Documentation should show which conditions were addressed and how they affected the medical decision-making process.
The presence of a condition in the patient’s medical record is not, by itself, sufficient to increase the E/M level. The condition must be relevant to the services provided and supported by the documentation for that encounter.
How Should a 30-Minute Low-Risk Antepartum Visit Be Coded?
Scenario: A healthy, low-risk pregnant patient has a 30-minute antepartum visit with a physician or other qualified healthcare professional (QHP). The encounter includes evaluation of the patient’s health and risk status, vital signs, fetal heart rate, fundal height, review of laboratory results, patient education, and shared decision-making.
Beginning on 1/01/2027, antepartum visits will be reported with the correct E/M code for the care rendered. The provider can choose either Medical Decision Making (MDM) or total time, for the date of the encounter.
Can the Visit Be Selected Based on Time?
Yes. If the provider uses the time-based E/M method, CPT® requires reporting the total time spent on the date of the encounter, rather than reporting a time range.
The 30-minute scenario should therefore be evaluated under the applicable E/M time requirements rather than assuming that face-to-face time alone determines the code.
What Activities Can Count Toward Total E/M Time?
When performed on the date of the encounter, physician or QHP time may include:
- Preparing for the patient, such as reviewing tests
- Obtaining or reviewing a separately obtained history
- Performing a medically appropriate examination or evaluation
- Counseling and educating the patient or family
- Ordering medications, tests, or procedures
- Referring or communicating with other healthcare professionals when not separately reported
- Documenting clinical information in the medical record
- Independently interpreting results when not separately reported
- Communicating results to the patient or caregiver
- Care coordination when not separately reported
This is particularly relevant to prenatal visits that include education and shared decision-making, because qualifying activities performed on the date of service may contribute to the total E/M time.
What Time Should Not Be Included?
Certain activities are excluded from the total E/M time. These include:
- Time spent performing services that are reported separately
- Travel time
- General teaching that is not specific to the management of the individual patient
What If the Provider Uses MDM Instead of Time?
Time is not the only method available. The provider or QHP can select the E/M service based on MDM when that method appropriately reflects the encounter.
If MDM is used, documentation should support all three elements:
- Number and complexity of problems addressed
- Amount and complexity of data reviewed and analyzed
- Risk of complications and/or morbidity or mortality of patient management
The CPT® code set does not establish a hierarchy in which MDM must be used instead of time, or vice versa. The appropriate method depends on the individual encounter.
What Should Be Documented for a 30-Minute Prenatal Visit?
For a time-based E/M service, documentation should support the total time spent on the date of the encounter and the services performed during that time.
For an MDM-based service, documentation should support the applicable problems, data, and risk that contributed to the selected E/M level.
While reporting overall time is required for CPT®, third party payers may ask for more specific information on time spent. Practices also need to take into account any payers’ documentation requirements.
Key Takeaway
The 30-minute low-risk prenatal visit is not an E/M code, but rather a concept. The encounter should be coded the appropriate MDM or total-time coding approach for antepartum care, with documentation supporting the approach and level of E/M coding for the encounter, under the CPT® 2027 coding framework.
Prepare for CPT® 2027 Antepartum Coding With CureCloudMD
OBGYN practices will need to make changes to their coding, documentation, charge capture, and claim workflows for the transition to encounter-based antepartum E/M reporting. Coding accurately for MDM or time-based E/M requirements, pregnancy-related diagnosis coding, modifiers and Payer-specific guidelines will be vital for clean claims.
CureCloudMD‘s OBGYN medical billing and coding services empower OBGYN practices to handle prenatal claims, document reviews, specific coding rules, and payer requirements. As the rules for maternity coding continue to change, our team assists practices in keeping their revenue cycle efficient from charge capture to claim submission, to denial management and A/R follow-up.
