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Thread: vaginal foreign body removal

  1. #1

    Default vaginal foreign body removal

    AAPC: CPC Promo
    We had a patient that came in w/ c/o pain after sex. During the exam a condom was found in the vagina. Is there a code for vaginal foreign body removal?
    adrianne, cpc

  2. #2

    Default

    57415: Using a vaginal speculum, the physician removes a foreign body lodged in the vagina. During the procedure, the patient is under general anesthesia because of the patient's inability to tolerate the procedure while awake, as in the case of a young child or due to the type or size of the object being removed.

    Then my encoder says:

    Excludes removal of impacted vaginal foreign body without anesthesia (99201-99499)

    Hope that helps!

  3. #3
    Join Date
    Apr 2007
    Location
    Greeley, Colorado
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    Default

    Adrianne - in your case just an E/M. Would be the same for a retained tampon removed in the office.
    Lisa Bledsoe, CPC, CPMA

  4. #4

    Default

    This pt was in the office not under anesthesia so I guess it's included in the exam. Kind of seems wrong .
    Lisa, it was a condom, I'm sure that doesn't matter???
    thanks
    adrianne, cpc

  5. #5
    Join Date
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    Default

    It doesn't matter what is "in there". Unless under anesthesia in the OR, only an E/M is reportable. It does seem wrong - it's a messy, smelly problem and there really should be more reimbursement for something like that - I agree!
    Lisa Bledsoe, CPC, CPMA

  6. #6

    Default

    Thanks to you both.
    adrianne, cpc

  7. #7
    Join Date
    Apr 2007
    Location
    New Port Richey & Gulf to Bay
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    108

    Default Question!

    What would be the appropriate code for when the provider excises and sutures out the foreign body (retained sutures) and granulation tissue from the vagina? Thank you.

  8. #8

    Default

    I have that same question as it is on the number 3 code a round for OBGYN. Everything I think it should be is not. It does get a bit frustrating when I engage the whole department and we all have basically the same answers. The CPT for this is 57415. I still am looking for the DX.

  9. #9
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    New Port Richey & Gulf to Bay
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    Default

    Quote Originally Posted by newellj View Post
    I have that same question as it is on the number 3 code a round for OBGYN. Everything I think it should be is not. It does get a bit frustrating when I engage the whole department and we all have basically the same answers. The CPT for this is 57415. I still am looking for the DX.
    I was thinking of using 939.2 (Foreign body in vulva and vagina) for the diagnosis code.

    When I read the lay description for 57415 (Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than local), It doesn't describe what the provider actually performed. The lay description states:

    "Using a vaginal speculum, the physician removes a foreign body lodged in the vagina. During the procedure, the patient is under anesthesia (other than local) because of the patient's inability to tolerate the procedure while fully alert or awake, as in the case of a young child or due to the type or size of the object being removed."

    The case I had encountered the provider excised the granulation tissue and then extended the incision to tunnel down to the retained suture which was then removed. So I'm conflicted on which code would be appropriate. Any suggestions?

  10. #10

    Default ICD 9 retained suture in vagina

    This question was asked in March because the question is in the OBGYN code a round and here I am in May doing the same code a round and I can't find the answer either.
    I have the cpt code but every DX that I think it could be it is not!
    Any suggestions?

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