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CPT® Code 59409 is designated for the reporting of vaginal delivery only, which may occur with or without the use of an episiotomy and/or forceps. This code is specifically utilized when the physician performs a vaginal delivery without the inclusion of comprehensive antepartum and postpartum care, which is instead reported with CPT® Code 59400. The common language description emphasizes that routine obstetric care encompasses a series of prenatal visits, labor management, and postpartum follow-up, but when only the delivery is performed, CPT® Code 59409 is appropriate. The procedure involves the physician's active participation in monitoring the health of both the mother and fetus throughout the labor process, ensuring that the delivery is conducted safely and effectively. The use of this code indicates that while the delivery itself is a critical component of obstetric care, it is distinct from the broader scope of services that include prenatal and post-delivery management, which are captured under different codes. This distinction is essential for accurate medical coding and billing, ensuring that healthcare providers are appropriately reimbursed for the services rendered during the delivery process.
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The indications for using CPT® Code 59409 include the performance of a vaginal delivery in cases where comprehensive antepartum and postpartum care is not provided. This may apply to patients who are admitted for labor and delivery without the need for ongoing prenatal visits or follow-up care after the delivery. The code is relevant in situations where the physician is focused solely on the delivery aspect of obstetric care, which may include the use of episiotomy or forceps if necessary.
The procedure for CPT® Code 59409 involves several key steps that ensure a safe and effective vaginal delivery. Upon the onset of labor, the patient is admitted to the hospital where an initial assessment is conducted by hospital staff. This assessment may determine the patient's ability to walk or engage in other activities during early labor. As labor progresses into the active phase, the physician begins to monitor both the mother and fetus through fetal heart monitoring, which is crucial for identifying any signs of fetal distress. If the labor proceeds without complications, the physician will facilitate the vaginal delivery. Should the need arise, an episiotomy may be performed to assist in the delivery process, and the physician may also utilize forceps or vacuum extraction as necessary to aid in the birth. After the baby is delivered, the umbilical cord is clamped and cut, followed by an evaluation of the newborn, including suctioning of the airways if required. The newborn is then handed to the parents or to another healthcare provider if further monitoring or care is needed. The physician is responsible for delivering the placenta and ensuring that it, along with the attached umbilical cord, is thoroughly evaluated. Additionally, the physician checks the uterus to confirm that all placental tissue has been expelled. If an episiotomy was performed or if there is significant vaginal tearing, the physician will suture the episiotomy or tear as part of the delivery process. Post-delivery, the physician provides any necessary inpatient care and follow-up, although this code does not encompass the full range of postpartum care, which would be reported separately.
Following the vaginal delivery, the physician provides any necessary inpatient post-delivery care, which may include monitoring the mother's recovery and addressing any immediate postpartum concerns. The physician is responsible for ensuring that the patient is stable and that any complications are managed appropriately. While this code does not cover comprehensive postpartum care, the physician may still conduct follow-up visits to assess the mother's health and recovery after discharge. It is important to note that any additional postpartum care provided would be reported using separate codes, as CPT® Code 59409 is strictly for the vaginal delivery component of obstetric care.
| Short Descr | OBSTETRICAL CARE | Medium Descr | VAGINAL DELIVERY ONLY | Long Descr | Vaginal delivery only (with or without episiotomy and/or forceps); | Status Code | Active Code | Global Days | MMM - Maternity Code | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 2 | CCS Clinical Classification | 135 - Forceps, vacuum, and breech delivery |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CG | Policy criteria applied | CR | Catastrophe/disaster related | GB | Claim being re-submitted for payment because it is no longer covered under a global payment demonstration | GK | Reasonable and necessary item/service associated with a ga or gz modifier | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SB | Nurse midwife | TG | Complex/high tech level of care | TH | Obstetrical treatment/services, prenatal or postpartum | U1 | Medicaid level of care 1, as defined by each state | U2 | Medicaid level of care 2, as defined by each state | U7 | Medicaid level of care 7, as defined by each state | U8 | Medicaid level of care 8, as defined by each state | U9 | Medicaid level of care 9, as defined by each state | UB | Medicaid level of care 11, as defined by each state | UC | Medicaid level of care 12, as defined by each state | UD | Medicaid level of care 13, as defined by each state | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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Notes
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| 2010-01-01 | Changed | Code description changed. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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