natashalage
Guru
Hello OBGYN coders, 
I have a question and I will greatly appreciate your rational to it. Thank you.
If Md did exam of Only vulva and/or vagina under anesthesia, will you code it as 57410 or 57410-52? I was thinking to use a modifier -52 because not all pelvic organs were examined. Per a description, this cpt is for exam of vagina, cervix, uterus, ovaries.. NCCI allows a modifier 52. What is the correct coding? Thank you very much.
Lay Description: Prior to the examination, the patient is placed under anesthesia, other than local, for a bimanual examination of the pelvic organs. The physician places two fingers inside the vagina to palpate the cervix, uterus, and ovaries while using the other hand to gently palpate the top of the uterus with pressure on the abdomen noting the organs' size, shape, and/or any abnormality.
I have a question and I will greatly appreciate your rational to it. Thank you.
If Md did exam of Only vulva and/or vagina under anesthesia, will you code it as 57410 or 57410-52? I was thinking to use a modifier -52 because not all pelvic organs were examined. Per a description, this cpt is for exam of vagina, cervix, uterus, ovaries.. NCCI allows a modifier 52. What is the correct coding? Thank you very much.
Lay Description: Prior to the examination, the patient is placed under anesthesia, other than local, for a bimanual examination of the pelvic organs. The physician places two fingers inside the vagina to palpate the cervix, uterus, and ovaries while using the other hand to gently palpate the top of the uterus with pressure on the abdomen noting the organs' size, shape, and/or any abnormality.
| Consumer Friendly Full | An exam of the pelvis and genitals while under anesthesia. |
| Consumer Friendly Short | Pelvic exam with anesthesia |