Wiki Cervical Polyp Removal GYN Coding HELP! New OBGYN Coder question.


Tampa, FL
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Hello everyone. A new coder to GYN and have a question about coding for an endocervical polyp removal. The only documentation for this was provided in the physical exam:
General: Normal vulva.
Vagina: No vaginal discharge, erythema, bleeding or lesions.
Cervix: Lesion (endocervical polyp flush with os) present. No friability.
Rectum: No external hemorrhoid.
Comments: Polyp removal attempted however unsuccessful due to polyp flush with cervical os; unable to grasp for removal. Hemostasis achieved with silver nitrate.

The provider only dropped an E/M code (99213). I am wondering if this needs an additional code for the attempted procedure with modifier 52. Does anyone have any advice?

Thanks in advance!
If that is the entire documentation, this would not warrant a procedure AND E&M with -25.
My usual advice would be to code for the procedure with -53. However, there is no exact code for a cervical polypectomy. The usual advice for that is to use either 57500 or 58999 unlisted. -53 is not valid on unlisted codes, so either 57500-53 or 58999.
In light of there being no exact code for this, AND the intended procedure could not be carried out, using an E&M only feels "less wrong" and I think would be a reasonable alternative in this situation.