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CPT® Code 59410 refers to the procedure of vaginal delivery only, which may include an episiotomy and/or the use of forceps, along with comprehensive postpartum care. This code is specifically utilized when a physician provides routine obstetric care that encompasses both the delivery of the baby and the subsequent care required for the mother after childbirth. The procedure begins with the physician conducting thorough prenatal evaluations throughout the pregnancy, which includes regular office visits to monitor the health of both the mother and the fetus. Upon the onset of labor, the patient is admitted to the hospital, where the physician oversees the delivery process. During active labor, continuous monitoring of the fetal heart rate is performed to detect any signs of distress. If necessary, the physician may perform an episiotomy or utilize forceps to facilitate the delivery. After the baby is born, immediate care is provided, including clamping and cutting the umbilical cord, assessing the newborn's health, and ensuring the delivery of the placenta. Post-delivery, the physician is responsible for suturing any tears or episiotomies and providing follow-up care to the mother, ensuring her recovery is monitored and supported. This code is distinct from others that may report different levels of care, such as antepartum and postpartum services combined with delivery or just the delivery itself.
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The procedure associated with CPT® Code 59410 is indicated for the following conditions:
The procedure for CPT® Code 59410 involves several key steps that ensure a safe vaginal delivery and appropriate postpartum care:
Following the procedure associated with CPT® Code 59410, the physician is responsible for providing comprehensive postpartum care. This includes monitoring the mother's physical and emotional recovery, addressing any complications that may arise, and ensuring that the mother receives appropriate education regarding newborn care and her own health. The physician will conduct follow-up visits to assess the healing process, manage any discomfort, and provide guidance on family planning and future pregnancies. The goal of this post-procedure care is to support the mother's overall well-being and facilitate a smooth transition into motherhood.
| Short Descr | OBSTETRICAL CARE | Medium Descr | VAGINAL DELIVERY ONLY W/POSTPARTUM CARE | Long Descr | Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care | 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) | 1 - Statutory 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 | Code Not Recognized by OPPS when submitted on Outpatient Hospital Part B Bill Type (12x/13x) | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 135 - Forceps, vacuum, and breech delivery |
| 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). | CG | Policy criteria applied | GB | Claim being re-submitted for payment because it is no longer covered under a global payment demonstration | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | TH | Obstetrical treatment/services, prenatal or postpartum | U1 | Medicaid level of care 1, as defined by each state | U7 | Medicaid level of care 7, 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 |
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| Pre-1990 | Added | Code added. |
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