Wiki Aetna denials for 59425 and 59426 - want # of units - denying 1 unit- and want all dates on claim?

Patricia Donegan

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Is anyone finding recent issues with AETNA? For OBGYN - when patients have a split in their global prenatal- we will bill out the antepartum care only codes 59425 (4-6 visits) or 59426 (7+ visits ) - depending on the # of visits patient had (less than 4 visits are converted to EM codes and not this code) The code is billed on one line- with from and to dates (ex: 8/03/22 to 12/19/22) and as 1 unit only. This is the way this code has always been billed to insurance - and is how ACOG and every payer advises to bill . Over the last several weeks- maybe even 2 months - I have been denied by Aetna for an odd reason- and one that I absolutely have not been able to correct! Further- I call Aetna repeatedly at 1-800- 624- 0756 - but simply cannot get a live representative- I keep getting pushed to a fully automated line and advised to go onto to Navinet. Which I do - but still cant get resolution. This is the denial in Navinet- cpt 59425 is billed- 1 unit- date 8/03/22 to 12/19/22 - and the error W25 -does anyone know what they want to get this claim thru? Do you list individual visit dates on the claim? by line item? Would you list 59425 on each DOS ? Is there something with the diagnosis that needs to be listed for each date? Maybe the gestational weeks for each visit? I could really use some advice if anyone else is having this issue. How do you respond to this W25 pend? I am getting NO WHERE! HELP!!!!

594251.000W25

Contractual ObligationW25:
Number of units does not match date span or modifiers. Please re-submit with individual date of service with matching modifiers and units. We need additional information in order to consider this charge. The information we need is explained on this statement. Please send us this information within 45 days from the date you receive this statement. We will make our benefit determination either (1) within 15 days after we receive the information we need or (2) within 45 days from the date you receive this statement, whichever is earlier. If we do not receive the information we need, this charge will be denied. The effective date of the denial will be the 46th day after the date you receive this statement. The basis for the denial will be that we do not have the information we need to consider this charge. You will have a right to appeal that denial at that time. For claims submitted from North Carolina, you have 90 days to respond to the request for information. If you fail to respond in 90 days, and receive a denial notice, you may submit the requested information within one year from the date the claim was denied and your claim will be reopened. This does not apply to Federal Plans. For claims submitted from Texas, we will make our benefit determination either (1) within 15 days after we receive the information we need, or (2) within other applicable statutory time periods that apply to you. For applicable provider claims submitted from Texas, your claim will remain open until you provide the requested information. This does not apply to Federal Plans. To ensure proper identification and tracking of this claim, you must include: the complete member name, complete patient name and the Member ID number. Please attach this information to this document and return to us. [PPND - W25]
 
Is anyone finding recent issues with AETNA? For OBGYN - when patients have a split in their global prenatal- we will bill out the antepartum care only codes 59425 (4-6 visits) or 59426 (7+ visits ) - depending on the # of visits patient had (less than 4 visits are converted to EM codes and not this code) The code is billed on one line- with from and to dates (ex: 8/03/22 to 12/19/22) and as 1 unit only. This is the way this code has always been billed to insurance - and is how ACOG and every payer advises to bill . Over the last several weeks- maybe even 2 months - I have been denied by Aetna for an odd reason- and one that I absolutely have not been able to correct! Further- I call Aetna repeatedly at 1-800- 624- 0756 - but simply cannot get a live representative- I keep getting pushed to a fully automated line and advised to go onto to Navinet. Which I do - but still cant get resolution. This is the denial in Navinet- cpt 59425 is billed- 1 unit- date 8/03/22 to 12/19/22 - and the error W25 -does anyone know what they want to get this claim thru? Do you list individual visit dates on the claim? by line item? Would you list 59425 on each DOS ? Is there something with the diagnosis that needs to be listed for each date? Maybe the gestational weeks for each visit? I could really use some advice if anyone else is having this issue. How do you respond to this W25 pend? I am getting NO WHERE! HELP!!!!

594251.000W25

Contractual ObligationW25:
Number of units does not match date span or modifiers. Please re-submit with individual date of service with matching modifiers and units. We need additional information in order to consider this charge. The information we need is explained on this statement. Please send us this information within 45 days from the date you receive this statement. We will make our benefit determination either (1) within 15 days after we receive the information we need or (2) within 45 days from the date you receive this statement, whichever is earlier. If we do not receive the information we need, this charge will be denied. The effective date of the denial will be the 46th day after the date you receive this statement. The basis for the denial will be that we do not have the information we need to consider this charge. You will have a right to appeal that denial at that time. For claims submitted from North Carolina, you have 90 days to respond to the request for information. If you fail to respond in 90 days, and receive a denial notice, you may submit the requested information within one year from the date the claim was denied and your claim will be reopened. This does not apply to Federal Plans. For claims submitted from Texas, we will make our benefit determination either (1) within 15 days after we receive the information we need, or (2) within other applicable statutory time periods that apply to you. For applicable provider claims submitted from Texas, your claim will remain open until you provide the requested information. This does not apply to Federal Plans. To ensure proper identification and tracking of this claim, you must include: the complete member name, complete patient name and the Member ID number. Please attach this information to this document and return to us. [PPND - W25]



Are those for Aetna commercial or Aetna Medicaid patients?

I am not an OB/GYN biller, but I did find an Aetna Better Health document that talks about individual E/M codes billed with a zero charge along with the antepartum codes. Could this be what you're encountering in your area too?

Here is the document I found. It references Pennsylvania, but it could be a starting point for research to see if that's how they want you to bill in your state too:

 
Is anyone finding recent issues with AETNA? For OBGYN - when patients have a split in their global prenatal- we will bill out the antepartum care only codes 59425 (4-6 visits) or 59426 (7+ visits ) - depending on the # of visits patient had (less than 4 visits are converted to EM codes and not this code) The code is billed on one line- with from and to dates (ex: 8/03/22 to 12/19/22) and as 1 unit only. This is the way this code has always been billed to insurance - and is how ACOG and every payer advises to bill . Over the last several weeks- maybe even 2 months - I have been denied by Aetna for an odd reason- and one that I absolutely have not been able to correct! Further- I call Aetna repeatedly at 1-800- 624- 0756 - but simply cannot get a live representative- I keep getting pushed to a fully automated line and advised to go onto to Navinet. Which I do - but still cant get resolution. This is the denial in Navinet- cpt 59425 is billed- 1 unit- date 8/03/22 to 12/19/22 - and the error W25 -does anyone know what they want to get this claim thru? Do you list individual visit dates on the claim? by line item? Would you list 59425 on each DOS ? Is there something with the diagnosis that needs to be listed for each date? Maybe the gestational weeks for each visit? I could really use some advice if anyone else is having this issue. How do you respond to this W25 pend? I am getting NO WHERE! HELP!!!!

594251.000W25

Contractual ObligationW25:
Number of units does not match date span or modifiers. Please re-submit with individual date of service with matching modifiers and units. We need additional information in order to consider this charge. The information we need is explained on this statement. Please send us this information within 45 days from the date you receive this statement. We will make our benefit determination either (1) within 15 days after we receive the information we need or (2) within 45 days from the date you receive this statement, whichever is earlier. If we do not receive the information we need, this charge will be denied. The effective date of the denial will be the 46th day after the date you receive this statement. The basis for the denial will be that we do not have the information we need to consider this charge. You will have a right to appeal that denial at that time. For claims submitted from North Carolina, you have 90 days to respond to the request for information. If you fail to respond in 90 days, and receive a denial notice, you may submit the requested information within one year from the date the claim was denied and your claim will be reopened. This does not apply to Federal Plans. For claims submitted from Texas, we will make our benefit determination either (1) within 15 days after we receive the information we need, or (2) within other applicable statutory time periods that apply to you. For applicable provider claims submitted from Texas, your claim will remain open until you provide the requested information. This does not apply to Federal Plans. To ensure proper identification and tracking of this claim, you must include: the complete member name, complete patient name and the Member ID number. Please attach this information to this document and return to us. [PPND - W25]
Aetna requires the medical records showing the number of antepartum visits the patient received in that time range (ie: the flowsheet). I've noticed recently that some other carriers are starting to require this as well.
 
United Health Care also wants the date range and prenatal notes for any 59425 or 59426 claim. It's such a huge PAIN!!!! Then they end up denying it anyway, even with all the documentation :cautious:
 
United Health Care also wants the date range and prenatal notes for any 59425 or 59426 claim. It's such a huge PAIN!!!! Then they end up denying it anyway, even with all the documentation :cautious:
Do they want this for a community plan also? I'm in Mississippi and we are having issues with denying for medical necessity for 59425/59426 and it says exceeded per day frequency or something along those lines.
 
I have always submitted claims for 59425 and 59426 on paper with the dates of the prenatal visits written on the claim along with attaching the prenatal flowsheet. Aetna still denies the claims and upholds the denial on appeal. Have any of you found a way to submit these codes that works on the first try?
 
I have been coding and billing for OBGYN for the last 15 years and I only put the last date the patient was seen on the claim for with either the 59425/6 and never have my claims denied nor do I normally have to provide notes. The only plan that I use a date range for is United Health Care. Hope this helps.
 
Just an update since I first posted this question- Aetna seems to require ONLY the date of the last prenatal visit- as the from and to - and 1 unit- and they paid all of my claims. They were previously paying us with a FROM and TO date- until about last fall. But after multiple corrected claims to them- I finally got them to pay. Empire BCBS also- seem to only want the date of the last prenatal visit. I can say also- that there were claims from the past few years- that we received payment with a FROM and TO date- but now we only use the last visit date. UHC on the other hand- requires that I include the FROM date and the TO dates - for prenatal care codes 59425 or 59426 - ex: 2/24/23 to 6/25/23 - and they sometimes do also request the notes- I DON'T automatically include them with the claim- I wait to see if they request. Most claims are paid without any requests for notes. And I often do get denials from all of the payers- and just appeal and send the supporting documentation and get most to pay. But agree- its a lot of work to track these- and appeal- and submit notes- they dont make it easy to get the doctors paid for services rendered in good faith to their members! Thanks all for your information and updates!!
 
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