Q&A: CPT documentation requirements for reporting VBAC procedures

Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean (VBAC) procedures?

A: The delivery note should include patient-specific, medically/clinically relevant details of:

• Complications
• Details of the delivery procedure (i.e., decision for the procedure, indications)
• Labor details (i.e., induction or augmentation)
• Maternal and newborn status after delivery
• Maternal–fetal assessment prior to delivery

VBAC means the patient had a previous cesarean. Even if she has given birth vaginally since that previous cesarean, a VBAC code would still be appropriate.

Clinical documentation should always be very patient-specific and coders should make sure that there is a maternal-fetal assessment, be it an ultrasound for a fetal location or fetal nonstress test (FNST). The fetal location may or may not be reportable, depending on who conducted it.

For example, did a doctor do it at the bedside or did radiology come in and do it? The same situation occurs with fetal nonstress tests (FNST)—if the doctor interprets it, they will likely want to bill that time. I’ve seen cases where the nurse practitioners are reporting and doing the antepartum care, but we’ve had the OB hospitalists come in and perform the FNSTs. That case would necessitate two billings with the two separate specialties.

Coders must look for all the labor details, including if it’s an induction or planned induction, whether the provider used drugs, and if they used a Cook balloon. If the providers inserted a cervical dilator or a Cook balloon more than 24 hours prior to delivery, the provider can report that service with CPT code 59200 (insertion of cervical dilator [e.g., laminaria, prostaglandin]), as established by CPT guidelines and the American Congress of Obstetricians and Gynecologists (ACOG).

Other details to look out for in documentation include information regarding the delivery procedure, clinical indications, and any associated complications, such as:

• Abnormal or stopped contractions
• Blood loss
• Failure of descent
• Fetal fever
• Fetal heart deceleration
• Maternal exhaustion
• Maternal fever

Maternal status after delivery and newborn status are also pieces of clinical documentation relevant to properly reporting the procedure.

If we look at successful VBACs, the available CPT codes to report are:

• 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

Editor’s note: This article originally appeared in JustCoding. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, AHIMA-approved ICD-10-CM/PCS trainer for Saint Alphonsus Regional Medical Center in Melba, Idaho, answered this question during the HCPro webinar, “ICD-10-CM and CPT Coding for Unusual Deliveries.”