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ED Coding and Reimbursement Alert

READER QUESTIONS:

Opt for E/M on Clamp Clot Clearup

Published on Sun Nov 27, 2011

Question: A 33-year-old non-pregnant woman presented to the ED with periumbilical pain after two days of heavy bleeding. The bleeding had decreased in the past two days, but the abdominal pain had increased to a 7 on a 10 scale. On examination, the physician discovers a large "clot" in the vaginal canal, which she removes with a clamp. Lab results report that the clot was "largely fibrinated blood and debris." The physician diagnosed vaginal bleeding. Is there a procedure code for the removal of the polyp (I was thinking 58558), or would I consider the clot removal when determining the E/M level? Georgia Subscriber Answer: You should consider the work to remove the clot when choosing your ED E/M code for this service (99281-99285). Remember to append 789.05 (Abdominal ED Coding Alert/2009, Vol. 12, No. 12 Get CPC® certified in 4 days -- CodingCert.com Page 95 pain, periumbilic) and 623.8 (Other [...]
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