Cpt 57456

[tkeeton7885]

I have a patient who was seen for an office visit for history of abnormal pap smear. The provider elected to perform CPT 57456. The office visit was coded with a 25 modifier with a diagnosis for abnormal pap smear (795.00). The procedure was coded with the pathology result of severe dysplasia. Is this appropriate or would I use the clinical findings only (abnormal pap smear) on the procedure also? Thanks in advance!

 

[kirkcr250]

In our office, we bill both the office visit and the colposcopy (57456) using the diagnosis from the pathology report, if dysplasia is found. I was always taught to code what you know at the end of the visit. If the pathology report comes back without any additional findings, we go back to the specific code from the most recent pap smear, ASCUS, LGSIL, etc. You are correct to use the 25 modifier on the office visit, although we don't always charge the office visit in addition to the procedure, if it was our physician who obtained the abnormal pap smear at a fairly recent visit. I would be interested to hear if anyone else does anything different. Thanks!