Ob-Gyn Coding Alert

Reviewed on April 21, 2015

Question: During an annual gynecological exam, the physician found a cervical polyp and removed it. The only polypectomy in the coding book that I see is 58558. Should I use this code, or is there a better alternative?

 California Subscriber

 Answer: For this procedure, you should use 57500 (Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]), which you should report whether the physician removed a lesion on the cervix (which can be a polyp) or performed a biopsy. 

 Note: You would report 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) when the ob-gyn removes a uterine polyp via the hysteroscope. Therefore this code does not fit this situation. 

 Remember: You should add 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 annual exam code (99384-99386 for new patients, or 99394-99396 for established patients) you report to indicate that the preventive service was separate and significant from the polyp removal. Also, don’t forget to link 622.7 (Mucous polyp of cervix) to 57500. In ICD-10, your diagnosis code will be N84.1 (Polyp of cervix uteri) instead.