melheffley
Networker
Hello everyone, I want to see if anyone out there can help me with a couple of pessary change scenarios. We have had some mixed reviews on what kind of e/m levels we should be billing for simple changes. I have included 2 notes from our office, from 2 different providers. Please let me know what you think each one should be coded as. Thanks in advance!!
1- Pessary change, c/o irritation to vagina.
#3 pessary changed
Tri Sans weekly
Ring forceps to remove because of pain & tight
Instructions given
Return 2 months
No ulcerations
2- Pessary change.
Feeling myuch better today. NO vaginal complains. Denies any vaginal bleeding, odor, itching/burning or pain (mild, usually discomfort)
Exam: Normal discharge, no bleeding, no ulcerations, 3* vaginal vault prolapse
Assessment: 3* cystocele, 3* uterine prolapse
Plan: #6 pessary ring with knob cleaned & changed. Will order a second one to change out/spare.
Recommend: Continue Estrace Vaginal Cream externally 2x week.
RTC 2mo & PRN
1- Pessary change, c/o irritation to vagina.
#3 pessary changed
Tri Sans weekly
Ring forceps to remove because of pain & tight
Instructions given
Return 2 months
No ulcerations
2- Pessary change.
Feeling myuch better today. NO vaginal complains. Denies any vaginal bleeding, odor, itching/burning or pain (mild, usually discomfort)
Exam: Normal discharge, no bleeding, no ulcerations, 3* vaginal vault prolapse
Assessment: 3* cystocele, 3* uterine prolapse
Plan: #6 pessary ring with knob cleaned & changed. Will order a second one to change out/spare.
Recommend: Continue Estrace Vaginal Cream externally 2x week.
RTC 2mo & PRN