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Thread: Leep

  1. #1

    Question Leep

    AAPC: Back to School
    I am new to coding OB-GYN and having difficult with a procedure.

    Pt had a LEEP (57460) earlier in the day and went back with vaginal bleeding and what the physician did was cauterized the LEEP site.

    Here is part of the OP note:

    There was bledding at 2 o'clock and 7 o'clock along with general oozing from the bed of the LEEP procedure. At that time, ball cautery was used to provide hemostatsis. Monsel solution was placed on a long Q-tip and held pressure on the LEEP site.

    I am not really sure what to use???

    Thanks for your help in advance.
    Connie - CPC

  2. #2


    Minor surgery categories are either 0 or 10 days global period.(medicare).
    This LEEP has a 0-Day global period and all pre-op and post op visits should be billed using office E/M Codes(99201-99215).
    For procedures with a global period of 10days, pre-op care still be charged using E/M codes. However you should not bill for Post Op services, related to normal recovery from the surgery during the 10_day post-op period.
    Treatment of complications is always a billable service, using the standard office visit E/M codes, linked to a diagnosis describing the complication.

    E/M visit codes may be charged the same day of a minor surgery or during the global post op period, IF A SIGNIFICANT, SEPARATELY IDENTIFIABLE SERVICE IS FURNISHED, Use a modifier -24 or 25, and document diagnosis carefully.
    Again, it is best to use a different diagnosis to clarify that the E/M service was UNREALTED TO THE PROCEUDRE.
    Hope this give you aclue

  3. #3


    That is great information but this was done in the OR. Patient was in recovery had complications and went back to the OR the same day.


  4. #4


    You would append modifier - 78 to the original procedure and electro cautery of the cervix 57510- 59.
    Ball cautery is only an electrocoagulation procedure.

  5. #5


    Thank you so much!

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