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

[kheslin87]

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:
Genitourinary:
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!

 

[csperoni]

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.