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Wiki Labia Separation

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TYSON1234

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Montrose, MI
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Looking for some assistance on the below procedure note. I'm leaning towards an office visit, since I can't find a CPT code


Procedure - Separation of labial agglutination
Preoperative diagnosis - labial agglutination
Postoperative diagnosis- labial agglutination
The area was cleaned with a betadine and then local numbing cream was applied and covered with sterile gauze for 20 minutes.
The area was checked on online and found to be adequately number for the procedure. Gently applying pressure with a sterile Q-tip on both sides of the middle and opening was opened to about 2 cm. At that point patient started getting uncomfortable so the procedure was concluded and was advised to use Premarin cream as before twice a day.
Complications none
Patient tolerated the procedure fairly well
 
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TYSON1234 said:
Looking for some assistance on the below procedure note. I'm leaning towards an office visit, since I can't find a CPT code


Procedure - Separation of labial agglutination
Preoperative diagnosis - labial agglutination
Postoperative diagnosis- labial agglutination
The area was cleaned with a betadine and then local numbing cream was applied and covered with sterile gauze for 20 minutes.
The area was checked on online and found to be adequately number for the procedure. Gently applying pressure with a sterile Q-tip on both sides of the middle and opening was opened to about 2 cm. At that point patient started getting uncomfortable so the procedure was concluded and was advised to use Premarin cream as before twice a day.
Complications none
Patient tolerated the procedure fairly well
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I would agree that an E/M visit should be coded instead of an unlisted procedure code. Look at the documentation to see if using total time will get you the highest level of service.
 
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