Aetna Issues Cross-Year Billing Guidance for 2027 Prenatal Claims

Aetna has announced interim billing guidelines for those providers who know the mothers they treat are expecting in 2027, and are implementing a cross-year approach to billing prenatal claims as part of the CPT restructuring that begins on Jan. 1, 2027. 

Aetna commercial and Medicare members are covered by the interim policy; Texas fully insured plans continue to be covered by applicable state regulatory requirements.

Aetna’s Cross-Year Prenatal Billing Instructions Overview

Aetna’s interim guidance establishes different billing treatment. The points they have provided are below:

Preventive Prenatal Visits With Three or Fewer Visits

• Applies to preventive prenatal visits performed on or after September 1, 2026.
• Use the applicable office E/M code.
• Append modifier TH.
• Include the appropriate pregnancy diagnosis codes.
• This approach applies when three or fewer prenatal visits occur before January 1.

Fourth 2026 Prenatal Visit

• Once the fourth prenatal visit occurs in 2026, return to the current antepartum coding rules.
• Use 59425 or 59426, as applicable.

Routine Prenatal and Postpartum E/M Visits

• Report routine prenatal and postpartum E/M visits as preventive services.
• Use modifier TH.
• Include supporting diagnosis codes.
• These preventive visits are submitted without member cost-sharing.

Visits for Complications or Other Conditions

• Do not append modifier TH when the visit addresses a complication or another medical condition.
• These visits may be subject to member cost-sharing.

Aetna confirms the 2027 service-level framework but says claims-processing, reimbursement, valuation, and fee-schedule details are still forthcoming.

Aetna Claim and Coding Updates for 2026!

Starting on December 1, 2026, Aetna is rolling out new claim edits via its Claim and Code Review Program (CCRP). The changes impact commercial, Medicare and Student Health members and are designed to facilitate proper claims processing and follow coding standards and guidelines. 

New Aetna Claim Edits Beginning December 1, 2026

As part of the CCRP, providers may also experience claim edits from Aetna starting December 1, 2026. Aetna's claims expenditure process is based on the industry coding guidelines and principles, such as Centers for Medicare & Medicaid Services (CMS) coding guidelines, American Medical Association (AMA) CPT® coding guidelines and evidence-based coding guidance developed by nationally recognized health care organizations and public health agencies. 

Providers can access information about these Aetna coding updates 2026 through the provider portal on Availity. For coding-related changes, providers can go to Aetna Payer Spaces > Resources and search for “expanded claim edits.”

Except for Student Health, providers can also use Aetna's code edit lookup tools to determine whether specific edits apply to a claim. Access to these tools requires an Aetna provider ID number (PIN) and login through Availity.

Medical Records for Selected Claims

In the claim review process, Aetna may ask for medical records for specific claims to assist in the accuracy of coding. These may include: 

• High-dollar claims
• Implant claims
• Anesthesia claims
• Bundled services claims

Providers in Washington, Texas, Maine, and Vermont should also note that the effective timing of some commercial-plan changes may vary according to applicable regulatory or statutory requirements.

Aetna Maternity Care Coding Changes for 2027

Aetna has announced major coding changes for commercial and Medicare members for maternity care services on January 1, 2027. The new framework, endorsed by the American Medical Association (AMA) along with the American College of Obstetricians and Gynecologists (ACOG) and other specialty organizations, will shift away from the rigid global billing framework to a more detailed and service-based approach to maternity reporting. 

Four Phases of Maternity Care Reporting

Under the new CPT® framework, maternity services will be reported across four separate phases:

• Antepartum (prenatal) care
• Labor management
• Delivery care
• Postpartum care

This service level coding system will replace global maternity codes starting January 1, 2027. The new framework is written to reflect existing provision for maternity care, such as individual and team-based care provision.

Changes to the CPT® Maternity Coding Framework

The AMA CPT Editorial Panel has made a few changes in the current coding structure for maternity, which have been approved: 

• 17 legacy maternity codes deleted
• 12 new maternity care codes added
• 6 existing codes revised

The coding structure has been established, but other information regarding implementation, such as operations and claims processing, is still to be expected. 

Aetna Preventive Prenatal Office Visit Billing

Prenatal and postpartum office E/M visits are preventive services and are exempt from member cost-sharing. These visits should be reported as modifier TH and different from non-routine prenatal and postpartum E/M visits (based on diagnosis code that is tied to the visit). 

Preventive Prenatal Visits

For patients expected to deliver in 2027, preventive prenatal visits provided on or after September 1, 2026 should be billed with the applicable E/M code, modifier TH, and the appropriate pregnancy diagnosis code(s) when three or fewer prenatal visits occur before January 1, 2027.

Modifier TH alone does not establish that a service qualifies as preventive. Providers should use the diagnosis associated with the specific office E/M visit to distinguish preventive care from non-routine services.

Billing After Four Prenatal Visits

Once four prenatal visits have occurred during 2026, billing should follow the current antepartum coding guidelines.

Office E/M visits related to medical conditions or complications during the prenatal or postpartum period should be documented and billed according to the medical reason for the encounter. These non-routine visits should not be reported with modifier TH and are subject to member cost-sharing.

Updated Preventive Care Guidance

Beginning September 1, 2026, providers are encouraged to review Aetna's updated Routine Preventive Care Benefit Guidance through the provider portal on Availity.

Providers should also review the updated maternity coding guidance before the January 1, 2027 implementation. Additional information on coding, valuation, reimbursement, and fee schedules will be provided as it becomes available.

How BillingFreedom Can Help

BillingFreedom can assist OBGYN practices with all aspects of the maternity coding changes that will occur in Aetna's 2027 coding system, including reviewing impacted prenatal visits, identifying preventive visits vs. condition-based E/M services, reviewing modifier TH, and confirming coding for pregnancy diagnosis, and checking that claims are in line with the revised maternity coding system for services. The team may also audit claims in the process of moving from global maternity reporting and uncover coding problems before they cause avoidable claim denials or payment delays. 

To learn more about our outstanding medical billing services, you may not hesitate to get in touch with us through email at info@billingfreedom.com or by phone at +1 (855) 415-3472. 

Our priority is your financial peace of mind!