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Thread: exam under anesthesia

  1. #1

    Default exam under anesthesia

    AAPC: Back to School
    I have a patient who is 6 yr old. Seen in the ER for injury from a falling on diving board.
    The injury needed to repair of a vulvar and perineal laceration.
    Unable to exam unless under general anesthesia . Do I code for the exam under
    anesthesia or do I just code for the repair. Also do I need to indicate the age of the patient?

  2. #2


    Examination under anesthesia 57410 would have to be reported separately.
    If this a recent and fresh injury, repair of injuryvagina,( and/or ) perineum nonobstetrical should be assigned with 57210.
    You would have to give an addundum modifier-59 .
    I hope it helps

  3. #3


    Thank you that was helpful.

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