CPT® Code 59610

1. Indications

The procedure described by CPT® Code 59610 is indicated for women who have a history of cesarean delivery and are seeking to deliver vaginally. The following conditions may warrant the use of this code:

• Previous Cesarean Delivery: The patient has undergone at least one cesarean section in the past.
• Desire for Vaginal Birth: The patient expresses a preference for a vaginal birth after cesarean (VBAC) due to personal, medical, or psychological reasons.
• Low-Risk Pregnancy: The patient is assessed to be at low risk for complications that would contraindicate a vaginal delivery.

2. Procedure

The procedure for CPT® Code 59610 involves several key steps that ensure comprehensive care throughout the antepartum, delivery, and postpartum phases:

• Initial Maternal History and Evaluation: The physician conducts an initial assessment of the patient's medical history, including previous pregnancies and deliveries, to evaluate the health status of both the mother and fetus. This assessment is crucial for identifying any potential risks associated with a VBAC.
• Regular Antepartum Visits: The patient attends scheduled prenatal visits, which occur monthly for the first 28 weeks, biweekly until 36 weeks, and weekly thereafter. These visits allow the physician to monitor the progress of the pregnancy, perform necessary examinations, and provide education on labor and delivery.
• Admission to Hospital: Upon the onset of labor, the patient is admitted to the hospital. Hospital staff perform an initial assessment to determine the stage of labor and the appropriate care plan.
• Continuous Fetal Heart Monitoring: During active labor, the physician utilizes continuous fetal heart monitoring to track the baby's heart rate and detect any signs of distress or complications, such as uterine rupture.
• Vaginal Delivery: If there are no contraindications, the physician facilitates a vaginal delivery. This may involve performing an episiotomy if necessary or using forceps or vacuum extraction to assist in the delivery process.
• Post-Delivery Care: After the baby is delivered, the umbilical cord is clamped and cut. The newborn is evaluated, and any necessary interventions are performed. The physician also delivers the placenta and examines it to ensure complete expulsion of placental tissue from the uterus.
• Suturing of Episiotomy or Tears: If an episiotomy is performed or if there is significant vaginal tearing, the physician sutures the area to promote healing.
• Postpartum Follow-Up: The physician provides postpartum care, including follow-up visits to monitor the mother's recovery and address any concerns related to her health or the newborn's well-being.

3. Post-Procedure

Post-procedure care following the delivery under CPT® Code 59610 includes monitoring the mother's recovery in the hospital, ensuring that she is stable and that there are no complications from the delivery. The physician will conduct postpartum visits to assess the mother's physical and emotional health, provide guidance on recovery, and address any issues that may arise. This follow-up care is essential for ensuring the well-being of the mother and the newborn, facilitating a smooth transition into parenthood.