Cesarean Section (Low Transverse)

CPT 59510
Approach Open
Add-on / Variant CPTs
  • 59515 — Cesarean delivery only (not including antepartum or postpartum care)
  • 59514 — Cesarean delivery only (no global care bundled — used with hospitalist model)
  • 59525 — Subtotal or total hysterectomy after cesarean delivery — add-on
  • 59618 — Routine obstetric care, cesarean delivery after attempted vaginal delivery
Preoperative Diagnosis:

[Failure to progress / non-reassuring fetal heart rate / malpresentation / repeat cesarean / placenta previa / prior uterine surgery] at [X] weeks gestation

Postoperative Diagnosis:

Same

Procedure Performed:

Low transverse cesarean section [with bilateral tubal ligation]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

[Spinal / epidural / general endotracheal]

Indications:

The patient is a [age]-year-old [female] G[X]P[X] at [X] weeks gestation presenting with [indication for cesarean]. [Primary / repeat] cesarean was recommended. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

A [male / female] neonate was delivered in the [vertex / breech] presentation with [clear / meconium-stained] amniotic fluid. Apgar scores were [X] at 1 minute and [X] at 5 minutes. Birth weight was [X] g. The placenta was [delivered intact / manually extracted], [complete / with a small retained cotyledon]. The uterine cavity was explored and found to be [empty]. The uterus was [well-contracted / required bimanual massage / required uterotonics].

Description of Procedure:

The patient was positioned supine with [left lateral tilt] to displace the uterus off the inferior vena cava. The abdomen was prepped and draped. A [Pfannenstiel] incision was made [2 cm above the symphysis pubis]. The fascia was incised transversely. The rectus muscles were separated in the midline and the peritoneum was entered. The bladder flap was created by [sharply / bluntly] developing the vesicouterine peritoneum and retracting the bladder inferiorly with a [bladder blade].

A low transverse uterine incision was made with a [scalpel / bandage scissors] and extended laterally. The amniotic membranes were ruptured. The presenting part was delivered with [direct pressure from the surgeon's hand / vacuum / forceps]. The cord was double-clamped and divided. The neonate was handed to the neonatal team.

Oxytocin [20 units in 500 mL LR] was administered intravenously. The placenta was [delivered with controlled cord traction]. The uterine cavity was explored and wiped with a moist lap sponge.

The uterine incision was closed in [2] layers with [0-Vicryl] running sutures: first layer locking, second layer imbricating [/ single layer]. The peritoneum was [closed / not closed]. The fascia was closed with [0-Vicryl]. Skin was closed with [4-0 Monocryl] subcuticular suture.

Sponge, needle, and instrument counts were correct at closure.

Complications:

None

Specimens:

Placenta, sent to pathology [if indicated]

Estimated Blood Loss:

[X] mL

Drains:

None / [JP drain]

Disposition:

The patient was taken to the recovery room in stable condition. The neonate was taken to the [newborn nursery / NICU]. Oxytocin infusion was continued. Diet was advanced as tolerated. Ambulation was encouraged on postoperative day 1. DVT prophylaxis was initiated.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: G***P*** at *** weeks, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Low transverse cesarean section
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Spinal/epidural/general

INDICATIONS: .PTAGE-year-old .PTSEX, G***P***, *** weeks, ***. Cesarean recommended. Consent obtained.

FINDINGS: *** neonate, *** presentation, *** amniotic fluid. Apgars *** / ***. Wt *** g. Placenta ***. Uterus well-contracted after uterotonics.

PROCEDURE:
Supine, left tilt. Pfannenstiel incision *** cm above symphysis. Fascia transverse. Rectus separated. Peritoneum entered. Bladder flap developed, retracted. Low transverse uterine incision — extended laterally. Membranes ruptured. Presenting part delivered ***. Cord clamped/cut. Neonate to team. Oxytocin *** units. Placenta ***. Cavity explored, wiped moist lap. Uterine incision: 2-layer 0-Vicryl (locking + imbricating). Peritoneum ***. Fascia 0-Vicryl. Skin 4-0 Monocryl. Counts correct.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: Recovery, stable. Neonate to nursery/NICU.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Classical Uterine Incision (Malpresentation / Extreme Prematurity)

A vertical uterine incision was used given [malpresentation with transverse lie and no lower uterine segment development / extreme prematurity at <28 weeks / anterior placenta previa obscuring the lower uterine segment]. The incision was extended vertically on the anterior uterine body. Classical incisions must be documented explicitly as they require cesarean delivery in all future pregnancies. The patient and her future obstetric providers must be counseled on this. Document the indication for classical incision and that repeat cesarean is required.

Charting Tips
  • Document uterine closure layer count and technique. One-layer vs. two-layer closure affects uterine scar integrity for subsequent pregnancies (VBAC candidacy, uterine rupture risk). Document number of layers, suture type, and whether the first layer was locking or running.
  • Document sponge, needle, and instrument counts explicitly. Retained surgical items (RSI) are a never event. Document 'sponge, needle, and instrument counts were correct × [2] at closure' in every cesarean. Retained items are most commonly sponges.
  • Document whether the peritoneum was closed. Non-closure of the parietal peritoneum in cesarean is associated with reduced surgical time, though evidence on adhesion formation is mixed. Document the decision; non-closure should be the documented choice, not an omission.
Billing Tips
  • Bill 59510 for cesarean delivery with antepartum and postpartum care (global OB package, 41.05 wRVU). Bill 59514 for cesarean delivery only (no antepartum care, 16.13 wRVU). Bill 59515 for cesarean with postpartum care only (22.79 wRVU).
  • The global OB package (59510) covers all antepartum visits, delivery, and postpartum care. Do not bill separate E/Ms for routine prenatal visits when billing the global package. If care is split between providers, bill the appropriate component code.
  • Maternity global period: the entire global OB package has a maternity global (not 90-day). The postpartum visit at 6 weeks is included. Early return for wound infection, uterine dehiscence, or readmission does not reset the global.
  • Hysterectomy at the time of cesarean (Cesarean hysterectomy) is separately billable. Bill the appropriate hysterectomy code (58150, 16.88 wRVU) with modifier -51 in addition to 59514. Document the indication (hemorrhage, accreta, uterine atony).
  • For repeat cesarean with lysis of adhesions, modifier -22 (increased complexity) may be appropriate if adhesiolysis significantly increases operative time. Document adhesion burden, time spent, and structures involved.