Ob-Gyn Coding Alert

Question: I have a provider who was present for a vaginal vacuum-assisted delivery, although they were not the delivering provider. The providers are from two different practices. Are we able to bill for separate delivery of the placenta?

AAPC Forum Subscriber

Answer: You have not indicated that your physician was the one who delivered the placenta, but rather it appears your physician was acting as an assistant during the birth. If that is the case, you should bill it out as an assistant for the birth with modifier 80 (Assistant surgeon) on the delivery-only code (59409, Vaginal delivery only (with or without episiotomy and/or forceps)). This will include delivery of the placenta.

Be prepared to send in documentation supporting the need for an assistant during a vaginal delivery. Usually, indications for a vacuum-assisted delivery may include such things as maternal exhaustion, a non-reassuring fetal heart rate tracing, a prolonged second stage of labor, or a need to shorten the second stage of labor due to particular maternal conditions such as cardiovascular or neurological disease. Be sure to check physician documentation so that you can report the correct code.

If your physician, not the delivering provider, delivered the placenta alone rather than assisting with the birth (which includes the delivery of the placenta), you can bill that instead with 59414 (Delivery of placenta (separate procedure)). But note that the delivering physician will be questioned about not providing all of the services. Both physicians should be in agreement on billing this case.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor