Does Granulation Tissue Cauterization Fall Under Postpartum Care?
Question: A patient presented to their gynecologist with perineal irritation and urinary frequency. Six months ago, the patient had a vaginal delivery with episiotomy repair. The physician performed a physical examination and found an area of granulation tissue along the healed episiotomy scar and mild urethral tenderness. The gynecologist ordered urinalysis and performed topical cauterization of the granulation tissue using silver nitrate. Can we charge for cauterization during an office visit? Connecticut Subscriber Answer: Yes, you may report the cauterization of the granulation tissue in a non-global period during an office visit. The patient presented six months after delivery of their child, which is past the initial postpartum period. According to the American College of Obstetricians & Gynecologists (ACOG), the initial postpartum period is 12 weeks following birth. Assign 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) to report the topical cauterization of the granulation tissue along the episiotomy scar using silver nitrate. You’ll also use an appropriate evaluation and management (E/M) code that matches the level of medical decision making — for example, 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.). You’ll also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to show that the E/M visit and the cauterization procedure are separate, significant services. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
