The top three teams from the fourth round group of six (held from February to October 2009) qualified for the 2010 FIFA World Cup.

Teams played home and away against their opponents, except three ties: Puerto Rico–Dominican Republic, Grenada–U.S.

Virgin Islands and Montserrat–Suriname, which were played over one leg in late March due to several Member Associations failing to meet the new FIFA Stadium standards and being unable to secure a home venue.

The six teams that reached the fourth round formed one double-round-robin, home-and-away group nicknamed the "Hexagonal."

The allocation of teams in the draw took place in Johannesburg, South Africa on 22 November 2008.

The draw for the order in which the two matches were played was held on 2 June 2009 during the FIFA Congress in Nassau, the Bahamas.