How To Use CPT Code 59612

CPT 59612 describes the procedure for vaginal delivery after a previous cesarean delivery, with or without episiotomy and/or forceps. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 59612?

CPT 59612 can be used to describe the procedure for vaginal delivery after a previous cesarean delivery. This code encompasses the delivery of the fetus and placenta, as well as any necessary interventions such as episiotomy and forceps. It is important to note that this code is specifically for vaginal delivery and does not include any additional postpartum care.

2. Official Description

The official description of CPT code 59612 is: ‘Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps).’ This code does not include postpartum care, which should be reported separately if provided by the same provider.

3. Procedure

1. The provider begins by admitting the patient to the hospital for delivery.
2. Intensive labor management is provided, including fetal monitoring and the use of low forceps and/or episiotomy if necessary.
3. The provider assists with the vaginal delivery of the fetus and placenta.
4. Immediate care is provided to the mother after delivery, including any necessary repairs or interventions.

4. Qualifying circumstances

CPT 59612 is used when a patient has previously undergone a cesarean delivery and is now attempting a vaginal delivery. This code applies to cases where the delivery is successful and does not involve any additional procedures such as a cesarean section or other surgical interventions. The use of episiotomy and forceps may be included in this code if necessary.

5. When to use CPT code 59612

CPT code 59612 should be used when a patient has had a previous cesarean delivery and is now attempting a vaginal delivery. It is important to ensure that the delivery is successful and does not require any additional surgical interventions. If the provider also provides postpartum care, this should be reported separately using the appropriate code.

6. Documentation requirements

To support a claim for CPT 59612, the provider must document the following information:

• Previous cesarean delivery
• Details of the vaginal delivery, including any interventions such as episiotomy or forceps
• Date and time of the delivery
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 59612, it is important to ensure that the procedure meets the specific criteria outlined in the code description. This includes a previous cesarean delivery and a successful vaginal delivery without the need for additional surgical interventions. If the provider also provides postpartum care, this should be reported separately using the appropriate code. It is also important to follow any additional guidelines or requirements set forth by the payer.

8. Historical information

CPT 59612 was added to the Current Procedural Terminology system on January 1, 1996. There was a code change on January 1, 2010, but no further updates have been made to the code since then.

9. Examples

1. A patient who previously had a cesarean delivery successfully delivers her baby vaginally, without the need for episiotomy or forceps.
2. A patient with a history of cesarean delivery attempts a vaginal delivery but requires the use of forceps to assist with the delivery of the baby’s head.
3. A patient who previously had a cesarean delivery delivers her baby vaginally and requires an episiotomy to facilitate the delivery.
4. A patient with a history of cesarean delivery successfully delivers her baby vaginally, without the need for episiotomy or forceps, and also receives postpartum care from the same provider.
5. A patient who previously had a cesarean delivery attempts a vaginal delivery but ultimately requires a cesarean section due to complications.
6. A patient with a history of cesarean delivery successfully delivers her baby vaginally, without the need for episiotomy or forceps, and also receives postpartum care from a different provider.
7. A patient who previously had a cesarean delivery delivers her baby vaginally and requires both episiotomy and forceps to facilitate the delivery.
8. A patient with a history of cesarean delivery attempts a vaginal delivery but ultimately requires a vacuum extraction due to difficulties during labor.
9. A patient who previously had a cesarean delivery successfully delivers her baby vaginally, without the need for episiotomy or forceps, and also receives postpartum care from a different provider.
10. A patient with a history of cesarean delivery attempts a vaginal delivery but ultimately requires a cesarean section due to fetal distress.