The Fourth Prenatal Visit Is Worth $194

Aetna printed the same sentence twice, a month apart. The second time it was longer.

August, in the OfficeLink Updates article on the maternity restructure: "For patients expected to deliver in 2027, preventive prenatal visits on or after September 1, 2026 should be billed with the applicable E/M code, modifier TH and pregnancy diagnosis code(s)."

September, same article, same heading, plus a clause: "...when three or fewer visits are provided before January 1, 2027. Once four prenatal visits have occurred in 2026, billing should follow the current antepartum coding guidelines."

The instruction went live Tuesday. So did the condition on it.

"Which side of December 31 is her fourth visit on?"

The Clause That Was Missing in August

The August sentence, read plainly, tells you to move every patient due in 2027 onto per-visit E/M starting September 1. That is a workflow change a billing manager can implement in an afternoon and a lot of them did, because the AMA is deleting 17 maternity codes on January 1 and 59425 and 59426 are two of them.

The September sentence says to do that only for patients who will accumulate three or fewer prenatal visits before New Year's Day.

Which is almost nobody. The schedule ACOG has recommended since 2017 is monthly to 28 weeks, every two weeks to 36, then weekly, for 12 to 14 office visits on a low-risk pregnancy, so a patient who books her first appointment this month reaches a fourth visit in December.

Under the September clause her 2026 antepartum care bills the old way, on codes that will not exist by the time she delivers.

Here is what makes this worth ten minutes of your morning: the clause is not Aetna's policy. It is the AMA's, and it was already in the book.

CPT 2026 carries a parenthetical instruction with the antepartum-only codes, quoted back by the AMA's own transition FAQ: "For 1-3 antepartum care visits, see appropriate E/M codes."

The four-visit line is the existing boundary between billing prenatal care as individual visits and billing it as a bundle. Nothing about 2027 moved it.

The AMA states the transition rule directly. Patients with four or more antepartum visits in calendar 2026 report them on 59425 (4-6 visits) or 59426 (7 or more), and patients with three or fewer report individual E/M codes, one per encounter.

Every 2027 encounter is an E/M, full stop, because the bundles are gone.

So Aetna's August bulletin instructed its network to do something CPT already prohibited for most of the patients it named. The September edition fixed it without saying it was fixing anything.