What CPT codes are used for postpartum visits?

Traditional postpartum visit (59430) is typically included in the global obstetric fee (59400/59510/59610/59618) which covers antepartum, delivery, and postpartum care. If billing separately (not global), use 59430. For complications or problems beyond routine postpartum care, use E/M codes (99213-99215). Depression screening uses 96127. New ACOG guidelines recommend multiple postpartum contacts.

How should postpartum depression screening be documented?

Document: screening tool used (Edinburgh Postnatal Depression Scale - EPDS, or PHQ-9), score obtained, interpretation (EPDS ≥10 or PHQ-9 ≥10 suggests depression), clinical assessment findings, patient response to positive screen, and plan (referral, medication, safety assessment if suicidal ideation). Bill 96127 for standardized screening with E/M visit.

What postpartum complications require separate documentation and billing?

Conditions beyond routine postpartum care billed separately: wound infection/dehiscence, postpartum hemorrhage evaluation, mastitis treatment, postpartum hypertension/preeclampsia management, thromboembolic disease, and postpartum depression treatment. Document as separate significant problem with own assessment and plan. Use E/M codes with appropriate ICD-10 diagnosis codes.

What documentation is required for postpartum contraception counseling?

Document: reproductive goals, all options discussed (including LARC effectiveness), breastfeeding considerations (estrogen effects on milk supply), method selected with rationale, and when to start (progestin-only OK immediately, estrogen delayed until 4-6 weeks postpartum). If inserting IUD or implant, document separately from global fee with procedure note.

How do I document the comprehensive postpartum assessment?

Document: physical recovery (pain, bleeding, perineal/incision healing, bladder/bowel function), breastfeeding assessment (if applicable), infant care adjustment, sleep quality, mood evaluation with standardized screening, social support, return to activity/work timeline, chronic disease management (glucose control if GDM, BP if preeclampsia), and birth spacing/contraception plan.

Postpartum Visit Template - 6 Week Checkup

OB/GYN — Postpartum Visit Template

OB/GYN Obstetrics Updated: 11/7/2025

The Postpartum Visit Template is designed for obstetricians, family medicine providers, and midwives conducting the standard 6-week postpartum visit following delivery. This comprehensive template documents maternal recovery, physical examination including pelvic exam, contraception counseling, mental health screening, breastfeeding support, and return to activity guidance. The template supports appropriate billing for postpartum visits (CPT 59430) and includes sections for delivery information and complications, postpartum recovery including bleeding, pain, and healing, breastfeeding or formula feeding status, mental health screening including postpartum depression assessment, physical examination including pelvic exam and healing assessment, contraception counseling and initiation, return to activity and exercise guidance, and ongoing care planning. This template ensures comprehensive postpartum care addressing both physical recovery and emotional well-being. Ideal for OB/GYN practices, family medicine practices providing obstetric care, midwifery practices, and practices managing postpartum complications.

Visit Information

Delivery date: [Date]
Weeks postpartum: [X] weeks
Delivery type: Vaginal / Cesarean / Other
Delivery complications: None / [Specify]

Postpartum Recovery

Bleeding: Resolved / Minimal / Ongoing (describe)
Pain: None / Mild / Moderate / Severe (location)
Incision healing: [If cesarean] Well-healed / Concerns: [specify]
Activity level: [Current activity, return to work status]

Breastfeeding / Infant Feeding

Breastfeeding: Exclusive / Partial / Formula only / Not breastfeeding
Breast concerns: [Specify concerns if any]
Infant feeding going well: Yes / No

Mental Health Screening

Mood: Good / Depressed / Anxious / Other
Sleep: Adequate / Disrupted
Support system: Adequate / Needs improvement
Postpartum depression screening: [PHQ-2 or Edinburgh score if used]
Concerns: [Document any mental health concerns]

Physical Examination

Vital signs: BP, HR, RR, Temp, Weight
General: Appearance, energy level
Breasts: [If breastfeeding concerns]
Abdomen: [Cesarean incision if applicable]
Pelvic exam: External, speculum, bimanual

Perineum: Healed / Episiotomy healing / Concerns
Cervix: [Appearance]
Uterus: Size, position, tenderness
Adnexa: [If indicated]
Pap smear: [If due]

Assessment

1) Postpartum status, [X] weeks

Recovery: Normal / Complications: [specify]
Mental health: Stable / Concerns: [specify]

2) [Other diagnoses as applicable]

Plan

1) Continue postpartum recovery

Activity: [Return to exercise guidance]
Follow-up: [If needed]

2) Contraception: [Method discussed and initiated]

[Method name] — [Instructions]

3) Mental health: [Support, counseling referral, medication if indicated]
4) Breastfeeding support: [If applicable]
5) Next visit: [Annual exam, other follow-up]

Patient Education

Postpartum recovery expectations, contraception options, mental health resources, return to activity, warning signs.

OB/GYN — Postpartum Visit Template

Template