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Urology Coding Alert

Reader Questions:

Sometimes E/M Is All You Can Code

Published on Wed Jul 16, 2008

Question: Our doctor performed a manual hernia reduction (peristomal incarcerated hernia) on a patient who has a stoma due to cystectomy. The patient exper-ienced a "sudden relief of the discomfort." Is there a CPT code I can use to report this service?Pennsylvania SubscriberAnswer: There is no specific code for the manual hernia reduction your urologist performed. You should include the service in the E/M service code that you report. For example, if the urologist documented a level- three service, report just 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).Diagnosis: Use ICD-9 code 569.69 (Colostomy and enterostomy complications; other complication, fistula, hernia, prolapse) for the diagnosis in this case.
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