Ob-Gyn Coding Alert

Question: A patient has a large glass object in the vagina still intact and not broken. The ED physician and ob-gyn attempted to remove it but failed. The ob-gyn decided to try to remove it under anesthesia - also unsuccessful. How should I report these failed attempts?

Nevada Subscriber
 
Answer: What you describe is in fact an "impacted" vaginal foreign body. You should report 57415-52 (Removal of impacted vaginal foreign body [separate procedure] under anesthesia; reduced services) for the failed attempt under anesthesia.
 
You should report the ED visit separately (using 99281-99285, Emergency department visit ...). Choose a code based on documentation that describes the degree of difficulty removing the foreign body. Make sure your ob-gyn's documentation reflects the actual site, what type of object, how it was placed, if any surrounding areas were affected and so on. Remember to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
 
CPT says an attempt to remove an impacted object without anesthesia is an E/M service only. Also, if the ED physician is reporting his services separately, your physician would report an outpatient E/M service code instead of an ED code.
 
For the diagnosis, you'll use 939.2 (Foreign body in genitourinary tract [vulva and vagina]) and you may also want to report an E code that better explains how the patient's condition came about.