Wiki Annual exam & cervical polyp

[dardegirl]

Can anyone out there tell me how they would code the following scenario:
Woman presents to the office for her annual exam. While doing the pap the provider finds a cerivcal polyp and removes it. How would you code this?

 

[carafry]

px w/polyp

Use the appropriate preventive visit code with a modifier -25 appended and the V72.31 diagnosis followed by 57500 (local excision of cervical lesion) with 622.7 polyp of cvx.

 

[dardegirl]

Much Mahalo (Thanks!)

 

[heathergirl]

question

How was the polyp removed and was it sent for biopsy?

 

[carafry]

a good point

A good point by heathergirl. What code would you use if not sent for bx? The only other possibility I was able to come up with would be to use the 11440 series of codes. I couldn't find anything relating to different methods of removal (only found different methods for destruction of lesion). Is there something else in the gyne codes that could be used?

 

[carafry]

regarding my last post

I was thinking about this and I re-read the code descriptor for the code I originally suggested, 57500. It does not matter if a biopsy was sent. The code states "biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration". There also is no mention of method, I believe because it is an excision, which assumes complete removal with a sharp blade as opposed to destruction which could be done by any number of methods. So I'm sticking by my first answer of preventive + 57500. Just figured I'd follow up on it.

 

[kbarron]

Polyp

Would you wait for the path report to come back before coding and billing?

 

[Lorisvg]

What if the polyp was twisted off, and not cut off?