How To Use CPT Code 59414

CPT 59414 describes the procedure for the delivery of the placenta, which is a separate procedure from the actual birth. 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 59414?

CPT 59414 can be used to describe the procedure in which a healthcare provider manually removes the placenta after delivery. This code is used when the provider examines the patient in lithotomy position to check for any retained placenta. The provider may use their hand to evacuate the placenta from the uterus while exerting pressure on the top of the uterus from outside. The goal is to ensure the patient’s uterus is contracting during the procedure to facilitate the removal of the placenta. Once the placenta is released, the provider examines it to ensure all tissue is complete.

2. Official Description

The official description of CPT code 59414 is: ‘Delivery of placenta (separate procedure).’ This code is used when the provider manually removes the placenta after delivery. It is important to note that this code is not used for antepartum care, which has its own specific codes (59425, 59426, or appropriate E/M code[s]). Additionally, if there were only 1-3 antepartum care visits, the appropriate E/M code[s] should be used instead.

3. Procedure

1. After the delivery, the patient is positioned in lithotomy position.
2. The healthcare provider examines the patient to check for any retained placenta.
3. If the placenta is retained, the provider inserts their hand into the uterus to evacuate the placenta.
4. Simultaneously, the provider exerts pressure on the top of the uterus from outside to aid in the removal of the placenta.
5. The provider ensures that the patient’s uterus is contracting during the procedure to facilitate the placenta’s release.
6. Once the placenta is released, the provider examines it to ensure all tissue is complete.

4. Qualifying circumstances

CPT 59414 is used when a healthcare provider manually removes the placenta after delivery. This procedure is necessary for all deliveries, whether the placenta is removed immediately after birth or at a later time. It is important to note that the delivering provider may not report this code, as it is typically performed by another healthcare provider.

5. When to use CPT code 59414

CPT code 59414 should be used when a healthcare provider manually removes the placenta after delivery. It is important to note that this code is not used for antepartum care or routine postpartum care. It is specifically for the separate procedure of removing the placenta.

6. Documentation requirements

To support a claim for CPT 59414, the healthcare provider must document the following information:

• Confirmation of a retained placenta
• Details of the procedure performed to remove the placenta
• Documentation of the patient’s position during the procedure (lithotomy position)
• Any anesthesia or sedation administered to the patient
• Confirmation of the patient’s uterus contracting during the procedure
• Examination of the placenta for completeness of all tissue

7. Billing guidelines

When billing for CPT 59414, ensure that the procedure was performed by a healthcare provider other than the delivering provider. It is important to note that all deliveries require the removal of the placenta, whether it occurs immediately after birth or at a later time. Therefore, this code should be reported for the separate procedure of removing the placenta. It is not appropriate to report CPT 59414 if the provider uses forceps or performs a manual extraction of the placenta. Additionally, it is important to follow any specific guidelines provided by the payer regarding the reporting of this code.

8. Historical information

CPT 59414 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A healthcare provider manually removes the placenta after a vaginal delivery.
2. During a postpartum examination, a healthcare provider discovers a retained placenta and performs the procedure to remove it.
3. After a cesarean delivery, a healthcare provider manually removes the placenta.
4. A patient experiences a delayed delivery of the placenta and requires a separate procedure for its removal.
5. Following a complicated delivery, a healthcare provider performs the procedure to remove the placenta.
6. During a routine postpartum check-up, a healthcare provider discovers a retained placenta and performs the necessary procedure to remove it.
7. After a forceps-assisted delivery, a healthcare provider manually removes the placenta.
8. A patient with a history of retained placenta requires a separate procedure for its removal during a subsequent delivery.
9. Following a successful vaginal delivery, a healthcare provider manually removes the placenta.
10. During a postpartum examination, a healthcare provider discovers a partial placenta and performs the procedure to remove it.