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Wiki Vaginal biopsy coding

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meli990618@gmail.com

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Lutz, FL
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Procedure documentation:
The area(s) was prepped w/ Povidone Iodine. Local anesthesia was achieved w/ Lidocaine 1% w/o Epi.
Lesion 1
Location: LOWER ONE-THIRD 6 O'CLOCK
Size of lesion: 0.5 cm-1.00cm (2 lesions)
excision was performed w/ iris scissors. The lesions were completely removed. Hemostasis was obtained w/ suture.
Lesion 2
Location: upper one-third 7 o'clock
Size: <0.5 cm
The excision was performed w/ iris scissors. The lesions were completely removed. Hemostasis was obtained w/ suture.

The specimen(s) was/were not submitted to pathology-granulation tissue.

My Dr did code 57100 but she says she wasn't sure about this code. I believe the correct code should be 57105 since the tree lesions were sutured. However, I have a few questions in mind, are these codes per lesion or per site, it doesn't specify how many lesions are covered. How would you code this?

Thanks in advance!!!!
 
meli990618@gmail.com said:
Procedure documentation:
The area(s) was prepped w/ Povidone Iodine. Local anesthesia was achieved w/ Lidocaine 1% w/o Epi.
Lesion 1
Location: LOWER ONE-THIRD 6 O'CLOCK
Size of lesion: 0.5 cm-1.00cm (2 lesions)
excision was performed w/ iris scissors. The lesions were completely removed. Hemostasis was obtained w/ suture.
Lesion 2
Location: upper one-third 7 o'clock
Size: <0.5 cm
The excision was performed w/ iris scissors. The lesions were completely removed. Hemostasis was obtained w/ suture.

The specimen(s) was/were not submitted to pathology-granulation tissue.

My Dr did code 57100 but she says she wasn't sure about this code. I believe the correct code should be 57105 since the tree lesions were sutured. However, I have a few questions in mind, are these codes per lesion or per site, it doesn't specify how many lesions are covered. How would you code this?
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The AMA clinical vignette used to value code 57100 includes a description of one or more biopsies therefore, since only suturing is the difference between these 2 codes, 57105 would also include one or more biopsies.
 
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