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The CPT® Code 59612 refers to the procedure of vaginal delivery only, specifically after a previous cesarean delivery, which may occur with or without the use of an episiotomy and/or forceps. This procedure is commonly known as a vaginal birth after cesarean (VBAC). It involves a series of routine obstetric care practices that encompass both antepartum and postpartum care. The process begins with comprehensive prenatal office visits, where the physician conducts an initial maternal history and evaluates the health status of both the mother and fetus. These visits are structured to occur monthly during the first 28 weeks of gestation, transitioning to biweekly visits until 36 weeks, and then weekly visits as the due date approaches. When labor commences, the patient is admitted to the hospital, where initial assessments are performed by hospital staff to determine the appropriate course of action. Depending on the stage of labor, the patient may be permitted to walk or engage in other activities to facilitate the labor process. Continuous fetal heart monitoring is employed during active labor to ensure the well-being of the fetus and to detect any early signs of fetal distress or potential complications such as uterine rupture. If the labor progresses without any contraindications, the physician will proceed with a vaginal delivery. In cases where assistance is required, an episiotomy may be performed, and tools such as forceps or vacuum extraction may be utilized to aid in the delivery. 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 necessary. The newborn is then handed to the parents or to another healthcare provider if further monitoring or care is needed. The physician also delivers the placenta, examines it along with the attached umbilical cord, and ensures that the uterus is free of any remaining placental tissue. If an episiotomy is performed or if there is significant vaginal tearing, appropriate suturing is conducted. Post-delivery, the physician continues to provide care for the patient during her hospital stay and offers postpartum follow-up in the office setting.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure represented by CPT® Code 59612 is indicated for patients who have previously undergone a cesarean delivery and are seeking to deliver vaginally. The following conditions may warrant the performance of this procedure:
The procedure for CPT® Code 59612 involves several key steps that ensure the safe delivery of the baby through vaginal means after a previous cesarean section. The following procedural steps are outlined:
Following the vaginal delivery, the patient is monitored for any complications that may arise. Postpartum care includes assessing the mother's recovery, managing any pain or discomfort, and ensuring proper healing of any sutured areas. The physician will provide guidance on postpartum care, including physical activity restrictions, signs of potential complications, and follow-up appointments to ensure the mother's health and well-being. The patient is encouraged to discuss any concerns or questions during these follow-up visits to facilitate a smooth recovery process.
| Short Descr | VBAC DELIVERY ONLY | Medium Descr | VAGINAL DELIVERY AFTER CESAREAN DELIVERY | Long Descr | Vaginal delivery only, after previous cesarean delivery (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 |
| 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 | CG | Policy criteria applied | GC | This service has been performed in part by a resident under the direction of a teaching physician | U7 | Medicaid level of care 7, as defined by each state |
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| 2010-01-01 | Changed | Code description changed. |
| 1996-01-01 | Added | First appearance in code book in 1996. |
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