Cesarean Section (Low Transverse)
5951059515wRVU: 22.79 — Cesarean delivery only (not including antepartum or postpartum care)59514wRVU: 16.13 — Cesarean delivery only (no global care bundled; used with hospitalist model)59525wRVU: 8.32 — Subtotal or total hysterectomy after cesarean delivery (add-on)59618wRVU: 41.57 — Routine obstetric care, cesarean delivery after attempted vaginal delivery
[Failure to progress / non-reassuring fetal heart rate / malpresentation / repeat cesarean / placenta previa / prior uterine surgery] at [X] weeks gestation
Same
Low transverse cesarean section [with bilateral tubal ligation]
[Attending name], MD/DO
[Resident/PA name]
[Spinal / epidural / general endotracheal]
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.
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].
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 and extended laterally by blunt finger extension [/ bandage scissors reserved for thick myometrium]. 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 1000 mL LR] was administered as a slow continuous intravenous infusion after cord clamping (not as an IV bolus, to avoid hemodynamic instability). 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. The parietal peritoneum was not closed per current evidence-based practice [/ closed per surgeon preference with documentation of rationale]. 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.
None
Placenta, sent to pathology [if indicated]
[X] mL
None / [JP drain]
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
.TODAYVariants
Classical Uterine Incision (Malpresentation / Extreme Prematurity)
A vertical uterine incision was used given [malpresentation with back-down transverse lie and no lower uterine segment development / periviable gestational age with undeveloped lower segment (typically <26 weeks; determined by anatomy, not by gestational age alone) / 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. Two-layer closure is the standard. Single-layer closure is not recommended when future pregnancy is possible — retrospective data links single-layer locking closure to higher uterine rupture risk, and scar imaging (niche geometry) is consistently better with two-layer. The 2Close RCT (Stegwee et al.) showing no difference studied non-locking technique and was underpowered for rupture. Default to two-layer; document number of layers, suture type, and whether the first layer was locking or continuous.
- 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 peritoneal closure decision. Non-closure of parietal and visceral peritoneum reduces operative time and hospital stay without increasing adhesions or infectious morbidity (Cochrane 2014, CORONIS trial). Non-closure is the evidence-based default; if the peritoneum was closed, document the rationale. Also document antibiotic prophylaxis: cefazolin [2 g IV, or 3 g if weight is 120 kg or more] administered within 60 minutes before skin incision, plus azithromycin 500 mg IV for non-elective cesarean performed after labor or membrane rupture (ACOG Committee Opinion 797, C/SOAP trial).
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 is separately billable using 59525 (subtotal or total hysterectomy following cesarean delivery, add-on code, 8.32 wRVU) billed in addition to the primary cesarean delivery code. Do not use the standalone hysterectomy code 58150 for cesarean hysterectomy; 59525 is the specific add-on. Document the indication (hemorrhage, placenta accreta spectrum, 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.
General coding reference. Verify with your institution’s billing department before submitting claims.