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What are the documentation requirements for vaginal deliveries?

Physicians must follow facility documentation guidelines, if any, when documenting delivery notes for vaginal deliveries. Physicians must also ensure that CPT code description elements for the code(s) reported are documented as applicable. CPT codes for vaginal delivery are as follows:

CPT Codes for Vaginal Delivery

59400

Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care

59409 

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

59410

Including postpartum care

59610

Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care, after previous cesarean delivery

59612

Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps);

59614

Including postpartum care

 

When facility documentation guidelines do not exist, the delivery note should include patient-specific, medically or clinically relevant details such as                                                                                               

  • Maternal–fetal assessment prior to delivery
  • Labor details, eg, induction or augmentation, if any
  • Details of the procedure, indications, if any, for OVD
  • Maternal status after the delivery
  • Complications, if any
  • Blood loss
  • Newborn status 

Before reporting, it is recommended that you talk to your payer(s) to see what their reporting policy is, if they have one. Be sure to get the information in writing. 

You may also want to purchase ACOG’s obstetrics and gynecology coding publication, OB/GYN Coding Manual: Components of Correct Procedural Coding. This manual is designed to educate physicians about accurate CPT coding of obstetric and gynecological surgical services. It also provides an authoritative opinion about the specific services included (or not included) in each obstetric and gynecological procedure code listed and detailed information about the specific services included (or not included) in each obstetric and gynecological procedure code according to Medicare’s Correct Coding Initiative.