2025 CPT code 59409

Vaginal delivery only (with or without episiotomy and/or forceps).

Use modifier 22 (Increased Procedural Services) if the work required for the vaginal delivery is substantially greater than usual due to complications or other factors. Do not report this code with antepartum or postpartum care codes if the delivery is included in a global maternity package.

Modifier 22 (Increased Procedural Services) may be appended to indicate significantly increased work associated with the delivery. Modifier 51 (Multiple Procedures) should not be appended to maternity care codes.

Medical necessity for this code is established by the patient being at term gestation and in labor, requiring skilled medical management for a vaginal delivery.

The physician's responsibilities include managing the labor process, which begins when the patient is admitted to the hospital. This involves an initial history and physical exam, assessing both mother and fetus, creating a treatment plan, and communicating with other medical personnel. The physician monitors the patient and fetus throughout labor, adjusting the treatment as needed. This may include inducing or augmenting labor.The physician also monitors uterine contractions and fetal heart rate, assists with delivery maneuvers, may perform an episiotomy or use forceps if required, and delivers the placenta. Finally, the physician examines for and repairs any lacerations.

IMPORTANT For vaginal delivery including postpartum care, use 59410. For antepartum care only, use 59425 or 59426. For postpartum care only, use 59430. For cesarean delivery, see codes 59510-59515. If all or part of the antepartum and/or postpartum patient care is provided except delivery due to termination of pregnancy by abortion or referral to another physician or other qualified health care professional for delivery, see the antepartum and postpartum care codes 59425, 59426, and 59430.

In simple words: This code covers the doctor's services for a vaginal delivery, including managing labor, and any necessary procedures like an episiotomy or using forceps. It doesn't include prenatal or postnatal care.

This code represents vaginal delivery only, encompassing admission to the hospital, admission history and physical examination, management of uncomplicated labor, and vaginal delivery (with or without episiotomy and/or forceps).It includes delivery of the fetus and placenta on the same date of service. It does not include antepartum or postpartum care.

Example 1: A pregnant woman at term presents to the hospital in labor. The physician manages her labor, which progresses normally. The baby is delivered vaginally without the need for an episiotomy or forceps., A pregnant woman at term requires induction of labor.The physician manages the induction and subsequent labor. The delivery is vaginal and requires an episiotomy due to perineal tearing., A pregnant woman at term experiences a prolonged second stage of labor. The physician uses low forceps to assist with the vaginal delivery. The placenta is delivered without complications.

Documentation should include a detailed description of the labor and delivery process, including the stages of labor, fetal monitoring information, any procedures performed (episiotomy, forceps), and the condition of both mother and baby after delivery. Any complications encountered during the process should be clearly noted.

  • Revenue Code: P1G - MAJOR PROCEDURE - OTHER
  • Global Days : Global days are not applicable to this code as it does not include postpartum care. If postpartum care is provided separately, use 59430 which has 10-day global period.
  • Payment Status: Active
  • Modifier TC rule: Not applicable.
  • Specialties:Obstetrics and Gynecology, Family Medicine
  • Place of Service:Inpatient Hospital, Birthing Center
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