# Vaginal delivery/ placenta/coding assistance



## CODING1234 (Feb 10, 2016)

I NEED ASSISTANCE CODING A VAGINAL DELIVERY, THE PATIENT PRESENTED IN THE ED WITH CONTRACTIONS, THE PROVIDER DOCUMENTED  THE H&P  LATER THE PATIENT HAD AN SPONTANEOUS VAGINAL DELIVERY WHICH THE PROVIDER ATTENDED AT THE END PER  REPORT BELOW.  WHAT CREDIT CAN I GIVE THE PROVIDER... SHOULD I BILL JUST THE H&P OR DELIVERY OF PLACENTA? PER NOTES  HE DID NOT DELIVERED THE INFANT.. ALSO THE NEXT ONE OF THE PROVIDERS WITHIN THE GROUP FOLLOW UP ON THE POST PARTUM FOLLOW UP AT THE HOSPITAL

PLEASE ADVISE

 there was delivery of a living female infant.  Apgars were 9 at one minute and 9 at five minutes.  Weight was 6 pounds 1 ounces (2745 g).  The placenta appeared grossly intact on evaluation, but will be sent to Pathology for evaluation.

OPERATIVE TECHNIQUE
The patient presented by EMS and was admitted earlier in the day for spontaneous rupture of membranes 

A Pitocin augmentation was initiated due to a dysfunctional labor pattern.

The patient progressed in labor.  Fetal heart tones remained reassuring.  Epidural was attempted, but the patient was unable to tolerate placement.  

At this point the patient remained 6 cm dilated, but quickly progress to a complete, complete exam.

The patient was unable to prevent pushing -> the infant's head was brought down to the vaginal introitus.  With continued maternal pushing there was a controlled spontaneous delivery of the infant's head by nursing.  The nose and mouth were then bulb suctioned.  With continued maternal pushing, the remainder of the infant delivered without difficulty.  

At this time, the physician entered the room.  The cord was then doubly clamped.  The cord was then cut by the infant's father.  Cord blood was obtained.  The placenta was allowed to spontaneously separate.  It appeared grossly intact at evaluation.  

Physical exam at this point, noted no visible lacerations.  Final physical exam at this point, noted a firm fundus with good hemostasis.  Mother and infant are currently doing well in the LDRP.


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## jennak73@gmail.com (Feb 22, 2016)

*vaginal delivery*

I am also having some difficulty coding this situation. Our provider made it in time to delivery the placenta and we also saw the patient for all of her antepartum and post partum care. Can we bill 59400, 22 with documentation stating we did not actually deliver the baby? Or do we have to split it into antepartum (59426), delivery of placenta (59414), postpartum in the hospital (99231,99238), and 6 week postpartum (59430)?


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## polcollinski (Mar 1, 2016)

I also have the same situation. From what I have found, if the OB was in contact with the hospital prior to the delivery, then you can code global. I am new to OB coding and not 100 percent sure of this. Any input is greatly appreciated.


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## lbuchs (Mar 16, 2016)

for global delivery, if the physician only delivers the placenta you would use modifier 52 on the delivery code. usually if the baby delivers before the physician can make it there they would say it was precipitate labor and you would need that code to show why the delivery was reduced (-52). I hope this helps.


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