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Wiki IUD Removal with E/M Code

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cbeste

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I would greatly appreciate thoughts on coding the following visit. A patient came in with various symptoms she felt were related to insertion of her IUD several weeks prior, including pelvic pain and burning with urination. The doctor took a chlamydia culture, removed her IUD, and coded for both a 99213 visit and a 58301 for removal of the IUD. In this instance, is an evaluation and managment code in addition to the IUD removal code appropriate? The history included a detailed description of her symptoms and the exam consisted of vital signs, general appearance, and a description of the IUD removal process. I'm not sure if a "significant, separately identifiable evaluation and management (E/M) service" is supported.
 
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