Cesarean or C-section is a surgical method of delivering a baby through an incision in the abdomen. According to the WHO stats, there is a rise in cesarean delivery, with more than 1 in 5 of all childbirths being from this method. This number is anticipated to rise over the coming decade, with 29% of all births likely to take place by C-section by 2030.
With the increased adoption of this method, physicians want to know the proper billing procedures for this service. So here is a complete guide for searching eyes on CPT code 59514.
CPT Code 59514 – Description
CPT code 59514 represents the cesarean delivery only.
The healthcare provider performs the delivery of the fetus and placenta through a surgical incision in the abdomen and offers immediate post-delivery care on the same day. This service excludes both antepartum and postpartum care. So, any services provided during the pregnancy or after the first day of delivery until 6 weeks are not covered by this code.
The physicians generally choose a C-section when a vaginal delivery may pose risks to either the mother or the infant. It helps manage complications during labor, including obstructed labor, fetal distress, or improper fetal positioning. The aim is to facilitate the baby’s safe arrival while reducing risks for both the mother and the newborn.
Scenarios Where CPT Code 59514 is Applicable
Let’s read some situations where CPT code 59514 may be applicable.
Emergency C-Section
Let’s think of our first scenario, where a pregnant woman experiences severe abdominal pain and heavy bleeding late at night. She has been receiving prenatal care from her private obstetrician at another clinic. Her family rushes her to the nearest hospital’s emergency department. Upon arrival, the on-duty obstetrician quickly examines her and realizes that the baby is in distress due to a serious condition where the placenta detaches from the uterus before delivery (placental abruption). Without delay, the attending obstetrician performs an emergency cesarean section to save both the mother and baby.
Since the on-duty physician performed the delivery procedure and did not provide any prenatal or postpartum care, CPT code 59514 is used to bill for the cesarean delivery only.
Unavailability of the Obstetrician
In another situation, suppose a woman who is getting close to her due date is brought to the hospital after her water breaks. The hospital’s on-call physician temporarily takes over her care while her regular obstetrician is away at a medical conference. However, problems occur during labor. The baby’s heart rate falls, and the physician decides that a C-section is required right away. The infant is delivered via cesarean section by the on-call physician.
The correct billing code in this case is CPT code 59514 because the on-call physician’s responsibilities were restricted to the delivery alone.
Out-of-Town Patient
A pregnant woman unexpectedly goes into labor while on her way to another city for a family gathering. However, the woman faces a sudden emergency on her way, so she is taken to the closest hospital. Upon arrival, it is discovered that the fetus’s heart rate is outside the normal range, which prevents a regular delivery. To safely deliver the baby, the attending physician chooses to conduct a cesarean section.
CPT code 59514 is the appropriate code to bill the local hospital obstetrician for surgical services because his responsibilities ended with the cesarean delivery.
Applicable Modifiers for CPT Code 59514
The following modifiers you may apply to CPT code 59514. However, you must support their usage by appending detailed documentation.
Modifier 22
Modifier 22 is applied to CPT code 59514 when submitting a claim for an extra cesarean delivery during a multiple-birth situation, like with twins, to signify that the provider spent more time and effort than the usual (increased procedural service) to deliver two babies via the same abdominal incision.
Modifier 80
If you served as an assistant surgeon during the emergency cesarean delivery, then consider applying modifier 80 to CPT code 59514. It indicates that you, a qualified physician, provided full assistance throughout the delivery.
Modifier 81
In reference to the above example, you may apply modifier 81 to CPT code 59514 if you provided minimal surgical assistance during the C-section delivery.
CPT Code 59514 – Billing & Reimbursement Guidelines
The following are some important guidelines that you must follow for accurate reimbursement against CPT code 59514.
Ensure the Correct Use of 59514
CPT code 59514 is applied when the provider performs a cesarean delivery only. This covers situations in which the surgery is the only reason the OBGYN gets called in. Prior to and following delivery, the patient is treated by another healthcare professional. An on-call, hospital-based, or locum tenens (temporary) OBGYN provides the service. However, if the same practitioner offers prenatal care, birth, and postpartum care, then he must apply the global code instead, which is CPT code 59510.
Provide Proper Documentation
When billing for CPT code 59514, your paperwork must include the following:
- Operative report with delivery details.
- Intraoperative notes.
- Statement confirming no antepartum/postpartum care provided.
- Indication for the cesarean (such as fetal distress, failed labor progression, breech presentation, or placental complications).
- Date and time of delivery.
- Type of anesthesia used and the name of the anesthesiologist (if applicable).
- Surgical technique (skin incision, uterine incision, delivery of the infant, placenta removal, closure).
- Complications or additional procedures performed, if any.
- Condition of the mother and baby post-surgery.
Verify Insurance Payers’ Coverage
Medicare reimburses CPT code 59514, but with proof of the medical necessity of the services. The Medicare Physician Fee Schedule (MPFS) determines how much Medicare pays for CPT code 59514, which varies by geographic location.
Since payments are modified to account for local practice costs, there is no one set nationwide amount. Particularly in cases involving elective cesarean sections, certain payers could need prior authorization or supporting clinical documentation. To avoid claim denials, it’s critical to review each payer’s medical necessity policy and coding rules.
Bottom Line
In short, you can bill CPT code 59514 for cesarean deliveries. However, this code does not cover prenatal or postpartum care. It only encompasses the delivery of the infant and placenta through an abdominal incision. You may apply this code in case of emergency deliveries, unavailability of the obstetrician, or patients’ relocation. Furthermore, the billing and reimbursement guidelines shed light on the essential information you must consider before submitting your claims.
If you are still unsure about its billing, you can hire a specialized OBGYN billing services provider. That way, you can rest assured that your C-section deliveries are accurately coded, claims are settled quickly, and your revenue cycle operates efficiently.
