CommercialBilling CodesHigh impact
Prenatal Care Provided by Primary Care Physicians (CPB 0047, reviewed 2026-03-10)
Aetna·Family Medicine, General Practice, OB-GYN·Medical Policy
Effective date
Oct 31, 1995
We identified it
Aug 13, 2026
Summary
Aetna has clarified billing requirements for primary care physicians providing prenatal care only. PCPs must use CPT 59425 (4-6 visits) or 59426 (7+ visits) for antepartum services, coordinate genetic testing through Aetna's Beginning Right Maternity Program, and refer patients to a participating obstetrician by week 28 for co-management and delivery. This policy requires immediate workflow updates to ensure compliance with billing codes, referral timelines, and enrollment requirements.
Action Required
IMMEDIATE ACTIONS REQUIRED: (1) Billing team must update billing software to enforce use of CPT 59425 (4-6 prenatal visits) or CPT 59426 (7+ prenatal visits) ONLY for primary care physicians providing antepartum care; do not use OB global package codes (59400-59410, 59510-59515). (2) Update encounter forms and clinical templates to require PCP documentation of: patient choice of PCP vs. obstetrician, enrollment status in Aetna Beginning Right Maternity Program, and fetal aneuploidy screening consent form completion. (3) Implement system flag: At week 28 visit, system must alert billing/clinical staff to verify referral to participating obstetrician has occurred and complete prenatal records have been transferred. Claims without evidence of week 28 referral may be denied. (4) Front desk/scheduling must confirm all referred obstetrician is 'participating' with Aetna before referral. (5) Before billing any genetic testing, ultrasound (76801-76817), or fetal non-stress testing (59025), verify ALL cases are coordinated through Aetna Beginning Right Maternity Program enrollment. (6) Providers must present fetal aneuploidy screening consent form in first trimester and document accept/decline. (7) Immediately enroll all qualifying pregnant members in Beginning Right Maternity Program before first prenatal billing. Failure to comply will result in claim denials and potential contract violations with Aetna.