2025 CPT code 99465
(Active) Effective Date: N/A Evaluation and Management - Delivery/Birthing Room Attendance and Resuscitation Services Evaluation and Management Feed
Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output.
Medical necessity is established by the presence of acute inadequate ventilation and/or cardiac output in the newborn immediately following delivery. This is typically evidenced by low Apgar scores, absent or inadequate respirations, bradycardia, and/or cyanosis.
The physician is responsible for assessing the newborn's condition immediately after birth, determining the need for resuscitation, and performing the appropriate interventions.This includes providing positive pressure ventilation and/or chest compressions. The physician also directs any additional procedures required as part of the resuscitation effort and documents the event thoroughly.
- Evaluation and Management
- Evaluation and Management, Delivery/Birthing Room Attendance and Resuscitation Services
In simple words: If a baby has trouble breathing or their heart isn't beating strong enough right after birth, the doctor will help them breathe using a mask and/or by pressing on their chest to help the heart pump. This is done right in the delivery room.
This code describes the resuscitation of a newborn in the delivery room who is experiencing cardiopulmonary distress.The physician provides positive pressure ventilation (PPV), using techniques like bag-mask ventilation, and/or chest compressions to address inadequate ventilation and/or cardiac output.This intervention is performed when the newborn exhibits signs of acute respiratory distress or circulatory failure immediately after birth.Procedures performed as a necessary part of the resuscitation (e.g., intubation, vascular lines) are reported separately.
Example 1: A newborn is delivered with a low Apgar score and is not breathing adequately.The physician provides PPV via bag-mask ventilation and initiates chest compressions until the newborn's respiration and heart rate stabilize., Following delivery, a newborn exhibits signs of respiratory distress, including cyanosis and gasping respirations. The physician provides PPV and supplemental oxygen, resulting in improved oxygen saturation and respiratory effort. , A newborn's heart rate drops significantly immediately after birth. The physician performs chest compressions and administers medications as needed to restore adequate cardiac output.PPV is also provided to ensure adequate oxygenation.
Documentation should include the indication for resuscitation, the methods used (PPV, chest compressions, etc.), the newborn's response to the interventions, and any additional procedures performed.The duration of the resuscitation and the condition of the newborn following stabilization should also be noted.
- Specialties:Neonatology, Pediatrics, Obstetrics
- Place of Service:Birthing Center, Inpatient Hospital