Wiki What codes to use

[jdibble]

Hi everyone,

My GYN doc has a question I am not sure how to answer - maybe I could get some help. Her questions is:

"I saw a patient for bleeding post intercourse. On exam found a polyp (cervical) and inflammation. I took the polyp off and treated the remaining area with histofreeze (cryo). How would I code this?

She did not give me any documentation yet to review. Can someone tell me what you would code and what code could be used for the polyp removal and for the histofreeze? Can the E/M be billed along with the procedures too.

Thanks,

 

[Charlotte Kay]

Reply

If the documentation is there,
57500
56501
and your E/M level with a modifier 25

As long as you did not have the pt scheduled for this procedure you can bill the E/M. And it doesn't sound like you did. Example if you had the pt scheduled for a colpo 57452, you would not bill for and E/M. At least that is how we do it here.