Ob-Gyn Coding Alert

Answer: CPT includes the use of forceps in the delivery code (for example, 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care). No payer will recognize this service separately.

Occasionally, you may be able to argue that a vacuum-assisted delivery required significantly more work than described by the delivery codes, especially if the birth was very difficult and the ob-gyn was in constant attendance. But you would have to provide documentation with the claim to support your assertions. If this is the case, the only way you could bill the extra work would be to append modifier -22 (Unusual procedural services) to the delivery code.