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E/M or Discontinued procedure?

  1. #1
    Default E/M or Discontinued procedure?
    Medical Coding Books
    I've posted this note before, but I couldn't remember what was bugging me about it (besides not being able to pinpoint the HPI elements, specifically)...Now I do remember, so I'm posting it again! Pay close attention to the exam and the plan - Would you consider this an E/M, or is it really more of a discontinued procedure? Please help!
    Visit Type: Scheduled follow-up
    Reason for visit (nurse documentation) 3mo pessary follow up appt and insert Femring
    CC: Pt to office for pessary check and insertion of femring. Pt has not been using her vagifem supp as directed.

    ROS: Constitutional: No fever, no chills, no weakness.
    ENMT: No decreased hearing
    Respiratory: No SOB, no cough
    CV: No chest pain, no palpitations, no peripheral edema
    GI: No nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
    GU: cystocele corrected with pessary. No dysuria, no urinary hesitancy
    Allergies: Cipro, Cyclobenzaprine, penicillin, sulfa drug
    Social History: Alcohol use: denied
    tobacco use: none
    Recreational drug use: denied

    Systolic BP: 155 mmHg HI
    Diastolic BP: 77 mmHg
    Heart rate on monitor: 57 bpm LOW
    BP Method: electronic measurements
    Weight: 64.410 kg
    Height Estimated in: 65 inch
    Weight lb: 141.7 lb
    BMI: 23.63
    General: Alert and Oriented. No acute distress.
    Neck: Supple, non-tender, no lymphadenopathy, no thyromegaly.
    Respiratory: Lungs CTA. Breath sounds are equal.
    GI: Soft, non-tender. Normal bowel sounds.
    GU: Normal genitalia for age. Vagina: Mucosa (Atrophy, dryness, vaginal introitus opening smaller due to atrophy. Not able to remove pessary without tearing vaginal opening today.)
    Integumentary: Warm, dry. Integumentary exam: Normal for ethnicity.
    Psychiatric: Alert and Oriented x4. Cooperative. Appropriate mood and affect.

    Diagnosis: Cystocele, Atrophic vaginitis
    Plan: Discuss using estrace cream to opening of introitus BID for next two weeks then follow up appt for removal of pessary and insertion of new femring. Pt educated on pessary care and douching and vaginal hygiene. Follow up sooner if problems.

    Provider coded as 99213 with primary diagnosis 627.3

  2. #2
    Removal and reinsertion of a Pessary is coded as an E&M as there is no CPT for this procedure. 57610 is for the fitting and insertion.

    Check out what I've found on the ACOG website:

    Best of Luck on your decision : )
    The Oracle

  3. #3
    Quote Originally Posted by MJ4ever View Post
    Removal and reinsertion of a Pessary is coded as an E&M as there is no CPT for this procedure. 57610 is for the fitting and insertion.

    Check out what I've found on the ACOG website:

    Best of Luck on your decision : )
    I actually found that exact page right after I posted the thread - Ha!

    I think my biggest hangup, is that this is a pessary removal, then femring insertion (The femring's an IUD, right?). Had the femring been inserted, would I still bill an E/M, or would I only bill the procedure code? I'll learn this eventually, I promise...

    Thanks for all of your help!

  4. #4
    I found this website for the femring. I didn't realize the part for the insertion of the femring when I read the note the first time.
    I looks like it is for treating menopausal symptoms

    I didn't find an insertion CPT for the femring.

    I know if a removal failed you usually code the CPT with a modifier 53 to show it was started but discontinued. But, I'm hesitant to recommend that, because would the Pessary be reinserted also?

    In my opinion, I would code an E&M only. If you code the E&M with the dicontinued removal of the pessary, you may get a denial for both E&M and procedure. Idk. I guess I see your dilema now.

    Maybe the provider is recommending the femring because the patient had not been using the vagifem suppositories. It would eliminate the constant use of suppositories.

    Let me know what you decide and how it plays out with the insurance.

    Happy Easter
    The Oracle

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