How To Use CPT Code 59300

CPT 59300 describes the procedure for episiotomy or vaginal repair performed by a healthcare provider other than the attending physician. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 59300?

CPT 59300 is used to describe the procedure of episiotomy or vaginal repair performed by a healthcare provider who is not the attending physician. This code is used when the provider makes an incision in the perineum, the area between the vagina and rectum, to facilitate the delivery of the baby’s head during childbirth. The provider then examines the birth canal and repairs any vaginal tears that need to be repaired. The episiotomy incision is closed with absorbable sutures.

2. Official Description

The official description of CPT code 59300 is: ‘Episiotomy or vaginal repair, by other than attending physician.’

3. Procedure

1. The patient is positioned in the lithotomy position, with knees bent and spread apart using stirrups.
2. The provider applies a local anesthetic to the perineum.
3. The provider makes a midline or mediolateral incision in the perineum using scissors or a scalpel.
4. The incision enlarges the vagina, facilitating the delivery of the baby’s head and body.
5. After the delivery of the baby and removal of the placenta, the provider examines the birth canal for any vaginal tears that need repair.
6. The provider repairs any first-, second-, third-, or fourth-degree vaginal tears.
7. The episiotomy incision is closed with absorbable sutures.

4. Qualifying circumstances

CPT 59300 is performed when an episiotomy or vaginal repair is necessary during childbirth. The procedure is typically performed by a healthcare provider other than the attending physician. The provider must assess the need for an episiotomy and determine the appropriate incision type (midline or mediolateral) based on the patient’s condition. The repair of any vaginal tears is also included in this code.

5. When to use CPT code 59300

CPT code 59300 should be used when an episiotomy or vaginal repair is performed by a healthcare provider other than the attending physician. This code is specific to the procedure and should not be used for other types of repairs or interventions. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 59300, the healthcare provider must document the following information:

• Indication for the episiotomy or vaginal repair
• Type of incision made (midline or mediolateral)
• Details of any vaginal tears that were repaired
• Use of local anesthetic
• Date and time of the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 59300, ensure that the procedure is performed by a healthcare provider other than the attending physician. It is important to accurately document the details of the procedure to support the use of this code. If there are any complications or additional repairs performed, separate codes may need to be reported. Review the documentation guidelines and any specific payer requirements to ensure accurate billing.

8. Historical information

CPT 59300 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates or changes since its addition.

9. Examples

1. A nurse practitioner performs an episiotomy during childbirth to facilitate the delivery of the baby’s head.
2. A certified nurse-midwife repairs a second-degree vaginal tear following a vaginal delivery.
3. A physician assistant performs a mediolateral episiotomy during a difficult delivery.
4. A nurse practitioner repairs a third-degree vaginal tear following a forceps-assisted delivery.
5. A physician performs an episiotomy and repairs a fourth-degree vaginal tear during a vacuum-assisted delivery.
6. A certified nurse-midwife performs an episiotomy and repairs a second-degree vaginal tear during a water birth.
7. A physician assistant performs an episiotomy and repairs a third-degree vaginal tear during a breech delivery.
8. A nurse practitioner performs an episiotomy and repairs a first-degree vaginal tear during a normal vaginal delivery.
9. A certified nurse-midwife repairs a second-degree vaginal tear following a twin delivery.
10. A physician performs an episiotomy and repairs a fourth-degree vaginal tear during a macrosomic baby delivery.