How To Use CPT Code 59610

CPT 59610 describes the routine obstetric care provided to a patient who has had a previous cesarean delivery. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 59610?

CPT 59610 can be used to describe the routine obstetric care provided to a patient who has previously undergone a cesarean delivery. This code encompasses all aspects of care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care. It is important to note that this code is specifically for patients who have had a previous cesarean delivery and are able to deliver vaginally during their current pregnancy.

2. Official Description

The official description of CPT code 59610 is: ‘Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery.’

3. Procedure

1. The provider begins by providing antepartum care, which includes evaluating the health status of both the mother and fetus, estimating gestational age, identifying any risk factors, and providing education and counseling related to the pregnancy.
2. Once labor begins, the provider manages the labor process, including monitoring the mother and fetus, developing a treatment plan, and communicating with the nursing staff.
3. If the patient is eligible for a vaginal birth after cesarean (VBAC), the provider may use low forceps or perform an episiotomy to assist with the delivery.
4. After the delivery, the provider performs postpartum care, which includes monitoring the mother’s recovery, providing pain management if necessary, and discussing postpartum care instructions with the patient.

4. Qualifying circumstances

CPT 59610 is specifically for patients who have had a previous cesarean delivery and are able to deliver vaginally during their current pregnancy. The provider must assess the patient’s eligibility for a VBAC and counsel the patient regarding the risks and potential benefits compared to a repeat cesarean. The code encompasses all aspects of routine obstetric care, including antepartum care, vaginal delivery, and postpartum care.

5. When to use CPT code 59610

CPT code 59610 should be used when providing routine obstetric care to a patient who has had a previous cesarean delivery and is able to deliver vaginally during their current pregnancy. It is important to ensure that the patient meets the criteria for a VBAC and that the care provided aligns with the components described in the code description.

6. Documentation requirements

To support a claim for CPT 59610, the provider must document the following information:

• Confirmation of the patient’s previous cesarean delivery
• Evaluation of the patient’s eligibility for a VBAC
• Documentation of antepartum care, including assessments, counseling, and education provided
• Details of the labor management, including monitoring of the mother and fetus, treatment plan, and communication with nursing staff
• Description of the delivery process, including any use of forceps or episiotomy
• Postpartum care documentation, including monitoring of the mother’s recovery, pain management, and postpartum care instructions

7. Billing guidelines

When billing for CPT 59610, ensure that the care provided aligns with the components described in the code description. It is important to accurately document the patient’s previous cesarean delivery and eligibility for a VBAC. Modifier 52, Reduced Service, may be added if the provider performs less than normal global care, and modifier 22, Increased Procedural Service, may be added if the provider’s work is greater than normal. It is important to review payer policies for specific billing guidelines and to ensure accurate coding and documentation.

8. Historical information

CPT 59610 was added to the Current Procedural Terminology system on January 1, 1996. There have been no updates to the code since its addition.

9. Examples

1. A patient who has had a previous cesarean delivery and is able to deliver vaginally during her current pregnancy receives routine obstetric care, including antepartum care, vaginal delivery, and postpartum care.
2. A provider evaluates a patient’s eligibility for a VBAC and provides routine obstetric care, including antepartum care, vaginal delivery, and postpartum care.
3. A patient with a previous cesarean delivery delivers vaginally with the assistance of low forceps, and the provider provides routine obstetric care, including antepartum care and postpartum care.
4. A provider performs a routine cesarean delivery for a patient who has had a previous cesarean delivery and provides postpartum care.