How To Use CPT Code 59618

CPT 59618 describes the routine obstetric care provided to a patient who has previously had a cesarean delivery and is attempting a vaginal delivery. 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 59618?

CPT 59618 can be used to describe the routine obstetric care provided to a patient who has previously had a cesarean delivery and is attempting a vaginal delivery. This code encompasses all aspects of care, including antepartum care, admission to the hospital for delivery, intensive management of labor, cesarean delivery if the vaginal delivery fails, and inpatient and outpatient postpartum care.

2. Official Description

The official description of CPT code 59618 is: ‘Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery 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 the gestational age, identifying any risk factors, and educating the patient on various aspects of the pregnancy.
2. If the patient goes into labor, the provider manages the labor, closely monitoring the mother and fetus, developing a treatment plan, and communicating with the nursing staff.
3. If the patient is attempting a vaginal delivery after a previous cesarean, the provider must be present at the hospital soon after the patient arrives. They continue to evaluate the patient’s and fetus’ condition throughout the course of labor, making any necessary adjustments to the treatment plan.
4. If it is determined that a vaginal delivery is not possible or safe, the patient is taken to the operating room for a cesarean delivery. The provider performs the cesarean delivery, ensuring the safety of both the mother and baby.
5. After the delivery, the provider transfers the patient to the recovery area and provides postpartum care, including monitoring vital signs, pain management, patient diet, and ambulation.
6. Outpatient postpartum care is also provided, which includes ongoing evaluation of the mother’s physical and mental status, physical examinations, lactation and nutrition counseling, birth control discussions, immunization evaluations, and collection of a screening Pap smear specimen if necessary.

4. Qualifying circumstances

CPT 59618 is used for patients who have previously had a cesarean delivery and are attempting a vaginal delivery. The provider must extensively review the patient’s delivery records to determine if they are a candidate for a trial of labor and counsel the patient on the risks and potential benefits of vaginal birth after cesarean (VBAC) compared to a repeat cesarean. The code covers all aspects of care related to the attempted vaginal delivery, including antepartum care, labor management, cesarean delivery if necessary, and postpartum care.

5. When to use CPT code 59618

CPT code 59618 should be used when a patient who has previously had a cesarean delivery attempts a vaginal delivery. It should not be used for patients who are not attempting a vaginal delivery or for patients who have not had a previous cesarean delivery.

6. Documentation requirements

To support a claim for CPT 59618, the provider must document the following information:

• Confirmation of the patient’s previous cesarean delivery
• Evaluation of the patient’s eligibility for a trial of labor
• Documentation of the patient’s progress throughout the antepartum period, including any complications or risk factors
• Details of the labor management, including monitoring of the mother and fetus, treatment plans, and adjustments made during labor
• Documentation of the decision to proceed with a cesarean delivery if the vaginal delivery fails
• Postpartum care provided, including monitoring of vital signs, pain management, patient diet, and ambulation
• Documentation of outpatient postpartum care, including physical examinations, counseling, and any additional procedures or tests performed

7. Billing guidelines

When billing for CPT 59618, ensure that the patient has previously had a cesarean delivery and is attempting a vaginal delivery. This code covers all aspects of care related to the attempted vaginal delivery, including antepartum care, labor management, cesarean delivery if necessary, and postpartum care. Modifier 22, Increased procedural service, may be added if the provider’s work is greater than normal. It is important to provide detailed documentation to support the use of this modifier.

8. Historical information

CPT 59618 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 previously had a cesarean delivery attempts a vaginal delivery. The provider provides antepartum care, manages the labor, performs a cesarean delivery when the vaginal delivery fails, and provides postpartum care.
2. A patient with a history of cesarean delivery goes into labor and attempts a vaginal delivery. The provider closely monitors the progress of labor, makes adjustments to the treatment plan as needed, and performs a cesarean delivery when necessary.
3. A patient who has previously had a cesarean delivery successfully delivers vaginally. The provider provides postpartum care, including monitoring vital signs, pain management, and patient education.
4. A patient with a previous cesarean delivery attempts a vaginal delivery but requires a cesarean delivery due to complications. The provider performs the cesarean delivery and provides postpartum care.