Internal Fetal Monitoring: CPT Codes 59050 and 59051
IUPC = Intrauterine Pressure Catheter
FSE = Fetal Scalp Electrode
May 17, 2015
Lori-Lynne A. Webb
CPC, CCS-P, CCP, CHDA, COBGC, CDIP
The definition of fetal monitoring involves the use of an electronic fetal heart rate monitor to record the baby's heart rate. Fetal monitoring is most commonly performed late in pregnancy and/or continuously during the intrapartum labor process to ensure a normal delivery of a healthy baby. Fetal monitoring can be utilized either externally or internally within the uterine cavity . External fetal monitoring is done via a fetal non-stress test, and is non-invasive. Internal fetal monitoring is done via fetal scalp electrodes and intrauterine pressure catheters. Internal fetal monitoring is done primarily during the labor processes. However, both internal and external monitoring have been used in some circumstances during labor.
The Intrauterine Pressure Catheter
The intrauterine pressure catheter (aka IUPC) is commonly used during labor and the induction of labor. The IUPC measures and denotes frequency, duration and strength of the contractions and if the patient requires additional medication(s) such as Oxytocin/Pitocin to augment the labor and move it along. The IUPC is a small flexible tube that is inserted into the uterus, to lie between the baby and the uterine wall. This device provides exact measurements of the contractions, unlike external monitors, or a Fetal Non-Stress Test (FNST) that is only monitoring the fetus.
The IUPC is primarily used when labor is progressing slowly or is stalling, or if the physician notices an irregular or abnormal contraction pattern. The IUPC also enables the provider to oversee that the uterine contraction process is strong enough, but not too strong, to ensure a smooth delivery for the fetus and the mother. In addition, an IUPC is typically left in place for the duration of the labor. Once the IUPC is inserted into the uterus, and verified to be functioning correctly, it is then attached to the patient’s leg to secure it.
An IUPC’s measurements are not affected by maternal movement and can also be used with fetal scalp electrodes (FSE) or other internal fetal monitoring devices during labor .
The fetal scalp electrode (FSE)
A fetal scalp electrode (FSE) placement is also billable/codeable under the CPT codes 59050 and 59051 or can be billed as an unlisted procedure with code 59899. An FSE is also bundled into the normal global delivery process. However, if the request of an FSE placement by the attending delivery physician is substantiated in the chart, to have the “consulting” provider insert the FSE, and oversee monitoring of the fetus, the “consulting” provider then has the opportunity to code for the placement, interpretation and , monitoring function of the FSE.
CPT has given coders codes 59050 and 59051 for reporting of fetal monitoring during labor.
• CPT Code: 59050 Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; supervision and interpretation
•CPT Code: 59051 Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; interpretation only
As you will note these two codes have some very important verbiage in them, that this monitoring has to be performed by a “consulting physician”. This means that if an attending provider is performing the entire intrapartum delivery and uses an IUPC or FSE, then it is bundled with the delivery itself. However, if the intrapartum attending provider calls in a specialist to perform or consult on the fetal monitoring, these codes become billable/codeable charges for the “consulting physicians”. You will note that codes 59050 and 59051 do not specifically state the usage of only an IUPC or FSE, but simply “fetal monitoring”. However, these are the most commonly utilized methods of fetal monitoring at this time.
Coding considerations for the consulting physician is to capture all codes that are applicable. In addition to the fetal monitoring, the actual “consultation” E&M can also be billed. As with any consultation you may need to determine if your payers will pay with a “consultation” code or if they would require a hospital based subsequent outpatient or inpatient code. If the consulting provider also performs and interprets a fetal NST, that interpretation service should be coded to capture the consultant physicians’ work for the NST. (59025-26)
Documentation for the FSE and IUPC require the consulting physician to have a separately identifiable documentation noting the request of their expertise by the attending physician. When an IUPC is used during labor, the intent is to measure the exact forces of the contraction(s) and make medical decisions based upon those findings. It must also be noted if the consultant physician is only providing the initial consultation, or if they will be continuing the supervision of the IUPC and that portion of the labor process. This is the difference when determining if to bill code 59050 which includes the written documentation, the supervision, and interpretation of findings. If the supervision is not going to be performed by the consulting physician, then it is appropriate only to bill the 59051, which does not include supervision.
Clinical documentation in the record should contain:
IUPC Uterine Contraction Monitor:
•Intrauterine pressure catheter (IUPC) provides a direct measurement of the intrauterine pressure in mmHg, as well as the frequency and duration of contractions.
•IUPC readings should be verified using uterine palpation as needed.
Mild: 15-30 mmHg above resting tone
Moderate: 30-50 mmHg above resting tone
Strong: 50-75 mmHg above resting tone
•Normal resting tone: 5-15 mmHg
Possible indications for IUPC monitoring include:
•When external methods do not provide accurate monitoring, such as in the case of maternal obesity or frequent changing of maternal position.
•To improve the interpretation of the timing of fetal heart rate decelerations in relation to uterine contractions.
•To determine the strength of contractions in cases of suspected labor dystocia or during labor induction or augmentation.
In the event of a multiple gestation:
•The usage of a monitor capable of simultaneously recording more than one fetal heart rate should be used, and all documentation should note and be separately identifiable of each fetus’ information.
•Abdominal palpation or additional ultrasound may be necessary for location of the placement of the IUPC monitors, or to ensure that each fetus is simultaneously monitored.
•An internal scalp electrode may facilitate monitoring, once membranes are ruptured.
Application of a Fetal Scalp Electrode
•General appearance of patient; and vital signs noted including maternal temperature
•Abdomen exam to include
uterine contractions denoting intensity, frequency, and relaxation between contractions.
•Fetal Heart Tones (FHT): baseline, variability, accels, decels (depth, length, alignment to contractions).
•Sterile Vaginal Exam: noting cervical dilatation/effacement/station.
•Fetal vertex presentation is confirmed.
•The FSE is applied to the scalp avoiding the fontanelles or suture lines to minimize scalp trauma.
•All documentation is recorded with date, time, and in depth procedure notes in the patients’ medical record/obstetric notes.
As the coder, if you are not seeing the majority of the documentation needed from the above lists, a query to the provider is in order. Below is a couple of actual clinical documentations to review:
I was called by the attending Midwife, Charlene Ekkles, CNM, to review the fetal strip for her patient that is in labor currently at 41 3/7ths weeks. Upon my review of the strip, Fetal monitoring was still showing variable fetal heart rate decelerations and hard to define uterine contractions that are not picking up on the monitor correctly. Patient is gravida 2, para 1 at 41 and 3/7 weeks with spontaneous rupture of membrane, 75% effaced and 2.5cm dilated. Patient had been laboring for the last 4 hours with no apparent progress and the appearance of incoordinate contractions at this time.
Pt’s abdomen is gravid, pt is obese. Pt appears pale but temperature is normal at 98.3, all vitals are stable. Previous strip shows occasions of incoordinate contractions. I discussed the IUPC catheter with the patient and her midwife, Ms. Ekkles. Patient would like to proceed with IUPC. I obtained consent from patient for the IUPC catheter to be placed.
IUPC placed to monitor contractions and to allow for amnioinfusion for variables if needed. Catheter was placed as per protocol, and EX C/7/0. Good Acceleration noted at the time of IUPC placement.. I have been asked to continue to monitor the patient and oversee the fetal responses in coordination with Midwife and global MD. Total time spent with patient was 15 minutes.
Initial IUPC readings: at 12:29pm after 3 contractions, during peak contractions, I calculated 300MVU’s with a resting tone of 15 mmHG, which appears that the patient has moved into a stabilized contraction pattern. I will oversee and coordinate care with Ms. Ekkles, CNM.
Janna Respoon, MD
99251-25 or 99231.25 (consultation or E&M subsequent)
59050 IUPC with supervision
659.73 – Abnormality in fetal heart rate and rhythm complicating labor and delivery
661.43 – Hypertonic, incoordinate, and prolonged uterine contractions
645.13 – Post Term Pregnancy
O76 - Abnormality in fetal heart rate and rhythm complicating labor and delivery
O62.4 - Hypertonic, incoordinate, and prolonged uterine contractions
O48.0 -Post-Term pregnancy
Rationale: In the scenario above the patients’ global care is being provided by the attending Certified Nurse Midwife. The Midwife, then requested Dr. Respoon’s expertise in the form of a consultation and ultimate care and oversight of the fetal monitoring. The IUPC interpretation is well documented, in addition to the documentation for the consultation/E&M of the patient.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at firstname.lastname@example.org or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.