CPT Code 59871 Removal of Cerclage Suture Under Anesthesia (Other Procedures for Maternity Care and Delivery)

CPT 59871 is defined by the American Medical Association (AMA) as “Removal of cerclage suture under anesthesia (other than local).”

This procedure code applies when a provider removes a cervical cerclage suture, a stitch placed earlier in pregnancy to prevent premature cervical dilation, under general, regional, or spinal anesthesia.

Unlike minor removals performed with local anesthesia during delivery, this code represents a separate, reportable surgical procedure, typically requiring a hospital or outpatient surgical setting.

Description of the Procedure

A cervical cerclage is placed during pregnancy to reinforce a weak cervix and prevent preterm birth or miscarriage. When the pregnancy reaches term, or if complications arise, the stitch must be removed.

For CPT 59871, removal is performed under anesthesia other than local due to patient discomfort, procedural complexity, or complications like scarring or embedded suture.

The provider performs the following steps:

1. Anesthesia administration - general, spinal, or epidural.
2. Speculum insertion to visualize the cervix.
3. Identification of the cerclage knot or suture.
4. Careful cutting and removal of the suture material.
5. Inspection of the cervix for bleeding, tearing, or infection.

This code is not included in routine maternity packages because it represents an independent surgical service requiring a higher level of care.

When to Use CPT 59871

You should report CPT 59871 when:

• The cerclage suture is removed under anesthesia other than local.
• The patient requires suture removal before delivery (e.g., for complications, infection, or preterm rupture of membranes).
• The removal is scheduled separately from labor or cesarean section.
• The procedure is performed in an operating room or surgical suite.

Do not report CPT 59871 when:

• The cerclage suture is removed under local anesthesia as part of routine obstetric care, this is included in the global delivery package.
• The removal occurs during cesarean delivery, it is bundled into that procedure.
• The suture is removed postpartum without anesthesia, typically included in global postpartum care.

Coding and Billing Guidelines

• Global Period: 10 days
• Site of Service: Hospital, ASC, or surgical suite (not office-based).
• Anesthesia Requirement: Must be documented as general, spinal, or epidural - not local.
• Preauthorization: Some payers may require approval if performed separately from delivery.
• Bundling Considerations: Removal during C-section or vaginal delivery is not separately billable.

Applicable Modifiers

• Modifier 59 – Distinct Procedural Service: If performed separately from other maternity procedures during the same encounter.
• Modifier 52 – Reduced Services: When only partial suture removal was possible.
• Modifier 78 – Return to OR: If performed due to complications within a global period.
• Modifier 22 – Increased Procedural Services: For complex removals requiring extended time or additional repair.

Documentation Requirements

Accurate documentation is essential for payer acceptance and audit defense. Include:

• Reason for removal (end of pregnancy, infection, rupture, pain, or embedded suture).
• Type of anesthesia used (general, epidural, or spinal).
• Location of service (hospital, ASC).
• Findings during removal, e.g., cervical edema, granulation tissue.
• Confirmation of complete suture removal.
• Postoperative status and follow-up plan.

Strong operative notes with anesthesia details and procedural justification ensure correct reimbursement and minimize denial risk.

Example Clinical Scenarios

Scenario 1 – Scheduled Removal Under Spinal Anesthesia

A 30-year-old woman with a history of cervical insufficiency had an abdominal cerclage placed at 14 weeks. At 37 weeks, she is scheduled for elective suture removal under spinal anesthesia before a planned C-section.

Code: CPT 59871

Rationale: Removal of cerclage suture under anesthesia other than local in preparation for delivery.

Scenario 2 – Early Removal Due to Infection

A 32-year-old patient at 33 weeks develops infection and discomfort around the cervix with an existing cerclage. The provider removes the suture under general anesthesia in the OR to prevent preterm rupture.

Code: CPT 59871

Rationale: Procedure requires anesthesia and surgical facility due to infection risk.

Scenario 3 – Embedded Cerclage with Complications

A patient presents postpartum with retained cerclage suture deeply embedded in cervical tissue, causing pain and bleeding. The provider performs removal under regional anesthesia in the operating room.

Code: CPT 59871 with Modifier 22

Rationale: Increased procedural complexity due to scarring and embedded suture.

Common Coding Challenges

Confusing Routine and Surgical Removals

Routine suture removals under local anesthesia are part of the global delivery package. Only removals requiring general or regional anesthesia qualify for CPT 59871.

Missing Anesthesia Documentation

One of the most common denial reasons is lack of explicit anesthesia detail. The operative note must specify the type used - “under anesthesia other than local.”

Bundled Service During Delivery

If the cerclage is removed during C-section or labor, it’s bundled with those procedures. Do not report separately unless performed at a distinct session.

Incorrect Site of Service

Office-based removals don’t qualify for this code. It must occur in a hospital or ASC setting.

Lack of Medical Necessity Justification

If removal is elective or premature, payers may request justification. Include clinical indications such as infection, pain, or cervical tension.

Overlapping Global Periods

If performed within the global maternity period, use appropriate modifiers (e.g., 78) and clear documentation to prevent claim denials.

Reimbursement Information

• Average Medicare Reimbursement: Approximately $250–$400, depending on region and site of service.
• Global Period: 10 days.
• Multiple Procedure Reduction: May apply when billed with another surgery.
• Preauthorization: Recommended for separate outpatient procedures.

Partner with BillingFreedom for Advanced OB-GYN Billing Support

Procedures like CPT 59871 demand both coding accuracy and regulatory compliance to ensure proper reimbursement. At BillingFreedom, our certified coders specialize in OBGYN medical billing services, managing everything from documentation audits to claim submission and denial prevention.

We help OB-GYN providers:

• Accurately code complex maternity and surgical procedures.
• Maintain compliance with CMS and AAPC updates.
• Minimize denials with proactive documentation and preauthorization checks.
• Achieve faster payments and improved revenue stability.

With BillingFreedom, your practice gains an expert partner committed to maximizing reimbursements while you focus on what truly matters, patient care.

For more details about our exceptional medical billing services, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472. 

Your financial tranquility is our priority!