Ob-Gyn Coding Alert

Reader Questions:

Clarify Vaginal Lesion Excision

Question: Before my physician placed an Altis sling for urinary stress incontinence, he noticed a small lesion in the vagina. He did excise this, as it looked pedunculated. The path report came back as benign vaginal mucosa. Would I code this as 57100 or 57061? Or am I not even close?

New Jersey Subscriber

Answer: Code 57061 (Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)) is for destruction, which you have not described. If you must code this service, go with 57100 (Biopsy of vaginal mucosa; simple (separate procedure)) but realize that it is a CPT® “separate procedure” which may be bundled and in addition the lesion was an incidental finding and normal, so that alone may get you a denial.