2025 CPT code 59410
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures for Maternity Care and Delivery Surgery Feed
Vaginal delivery with postpartum care; includes labor management, delivery of fetus and placenta, and inpatient and outpatient postpartum services.
Modifiers may be applicable depending on the complexity and extent of services rendered. For example, modifier 22 (increased procedural service) might be used in cases with significantly more work than routine care, requiring detailed justification.
Medical necessity is established by the need for the vaginal delivery and the subsequent postpartum care. The presence of labor and the birth of the child establish the need for delivery-related services. The postpartum care is medically necessary for the mother's recovery and to address any potential postpartum complications.
The physician is responsible for all aspects of care, from labor management to postpartum follow-up. This includes assessing and managing labor, delivering the baby and placenta, performing episiotomy and/or using forceps if needed, monitoring mother and baby post-delivery, providing medical advice, and conducting postpartum checkups.Any complications during labor or delivery would require appropriate additional codes.
In simple words: This code covers the entire process of vaginal childbirth, from labor to the postpartum period.It includes the doctor's care during labor, the delivery itself, and follow-up care for mom after the baby is born (in the hospital and later at checkups).
This comprehensive code encompasses vaginal delivery, including labor management (induction, monitoring, forceps use, episiotomy if needed), delivery of the fetus and placenta, and both inpatient and outpatient postpartum care. Postpartum care typically extends up to six weeks post-delivery, incorporating multiple outpatient visits.It includes monitoring vital signs, pain management (if necessary), dietary guidance, ambulation advice, and breast/vulva care instructions at discharge. Outpatient care covers physical and mental status evaluations, physical examinations (weight, blood pressure, breast/abdominal/pelvic exams), lactation counseling, nutrition and exercise guidance, birth control options review, immunization evaluation, and Pap smear collection (if appropriate). Preconception counseling might also be included to prepare the patient for future pregnancies.The intrapartum care involves continuous monitoring of the mother and fetus, adjustments to the treatment plan as needed, administration of anesthesia (if indicated), and various procedures like assisting the delivery with forceps or vacuum extraction.
Example 1: A 35-year-old primigravida (first pregnancy) presents to the hospital in active labor. The physician manages the labor, performs a vaginal delivery with an episiotomy, and provides inpatient and outpatient postpartum care. , A 28-year-old multigravida (multiple pregnancies) is admitted for induction of labor due to gestational hypertension. The physician manages the labor, performs a vaginal delivery with low forceps, and provides subsequent postpartum care, including addressing any complications related to the hypertension., A 40-year-old patient experiences an uncomplicated vaginal delivery and receives routine postpartum care including education and counseling on breastfeeding, contraception, and postpartum mental health.
Detailed documentation is crucial and includes: complete prenatal history, labor progress notes, delivery notes (including details of any interventions like episiotomy or forceps), postpartum recovery notes (inpatient and outpatient), vital signs, weight, blood pressures, any medications administered, and all patient counseling.
** This code represents a global package.Additional codes are needed to report any complications or extra services not included in the comprehensive nature of the 59410 code.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: Information not available in source. Refer to CMS fee schedules for current RVU values.
- Global Days : This is a global procedure with postpartum care typically spanning up to six weeks post-delivery.The global period includes the inpatient and outpatient services covered under this code.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule : Information not available in source. Refer to historical CMS fee schedules for data.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Birthing Center