A 27-year-old woman in labor presented to the emergency room. Upon admission and evaluation, it was determined that the fetus was in breech position. Due to the severity of the mother's contractions, the OB decided that tocolysis was necessary in order to delay the contractions to allow for an external cephalic version procedure. The OB and the delivery team of nurses carefully performed the external cephalic version and successfully turned the fetus into the appropriate delivery position, at which time the tocolysis was ceased and the patient was given Pitocin to begin contractions again. The baby was successfully delivered vaginally after three additional hours of labor.
How should the OB code for the procedure?

Question

Quizplus · Accepted Answer

The OB should code for the procedure with codes 59400, for the vaginal delivery. No additional modifier is necessary for this code. Code 59412 needs to be reported in addition to the delivery code, to indicate the additional service that was performed, in this case the external cephalic version procedure with tocolysis. Guidelines in the CPT manual after code 59412 indicate that it should be reported in addition to the code for the delivery. Modifier -51 and code 59412 should also be included on the claim to indicate that there were multiple procedures performed on the same date of service.

A 27-Year-Old Woman in Labor Presented to the Emergency Room