# retained pessary



## kls1027 (Mar 21, 2011)

I have a case where the patient had to have her gelhorn pessary removed under anesthesia because it was 'retained' due to an enterocele.  Would I code this 57415-Removal of 'impacted' vaginal foreign body or as 57410-Exam under anesthesia?    Thank you!


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## Lisawills08 (Feb 14, 2019)

kls1027 said:


> I have a case where the patient had to have her gelhorn pessary removed under anesthesia because it was 'retained' due to an enterocele.  Would I code this 57415-Removal of 'impacted' vaginal foreign body or as 57410-Exam under anesthesia?    Thank you!



I know this is old but did you ever find the answer? I have the exact same case.


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## csperoni (Feb 14, 2019)

*57415*

I was leaning to 57415 since it is not just an exam.  I found this posted as a confirming answer on supercoder website (obviously update your diagnosis coding to ICD10):

Coding for pessary removal:

If a patient comes into the office to have her pessary removed, cleansed, and reinserted, an appropriate evaluation and management code (99211-99215) should be reported, based on the key components performed (history, examination, and medical decision making), as this is considered part of the E/M service.

If a patient presents to your office for the removal of an impacted pessary, it is appropriate to report CPT-4 code 57415 (Removal of impacted vaginal foreign body under anesthesia). However, if this is performed without anesthesia, report an E/M code at the appropriate level instead. Report ICD-9 diagnosis code 996.39 (Mechanical complication of genitourinary, other) in addition to the patients other conditions such as 616.10 [Vaginitis], or 618.2-618.4 [Cystocele with uterine prolaspe].


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## Lisawills08 (Feb 14, 2019)

This is my OP note

Preoperative Diagnosis: Retained pessary.

Postoperative Diagnosis: Retained pessary.

Procedure: Examination under anesthesia, removal of a retained pessary.

Brief History: The patient is an elderly, frail 94-year-old female who has a Gellhorn pessary in place. As per my records, this has been in place for greater than 5 years without having been cleaned or changed. She is having a small amount of bleeding, but significant vaginal odor. due to the length of time that this has been in place, it is impossible to remove it in the office. She is brought for IV sedation and removal of the device. She and her family have been apprised of the risks of anesthesia and consent has been obtained.

Description of Procedure: Patient was taken to the operating room and anesthesia was established. when she had adequate sedation established, her legs were placed in the stirrups. there was noted to be clearish discharge from the vaginal vault. The knob of the Gellhorn pessary was visualized at the vaginal introitus. Initial attempts to remove the pessary were unsuccessful. Ultimately, the knob of the Gellhorn was grasped with the single-tooth tenaculum for traction with both hands, the suction was reduced, and at that point, the pessary was removed. there was a small amount of bleeding. a gentle speculum examination was carried out, which revealed some granulation tissue along the anterior and posterior walls of the vagina, but there was no active bleeding. There were no ulcerations and no fistula formation. The pessary was discarded and at the conclusion of the procedure, the patient was awakened from anesthesia and taken to the recovery room in stable condition with all counts correct.


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## csperoni (Feb 14, 2019)

It is 57415 for removal of the pessary under anesthesia.  The pelvic examination would be included.  Just like you include an exploratory laparotomy in any more comprehensive procedure done.


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## Lisawills08 (Feb 15, 2019)

Thank you very much for all the help! One more question. The diagnosis I have found to over it would be T19.2xx would this be initial encounter, subsequent or sequela? We put it in and seen her in the office before the procedure.


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## csperoni (Feb 15, 2019)

*Initial for active treatment*

For the surgery, it would be initial, T19.2XXA
Initial means active treatment (not necessarily only the first visit).  There is a very good AAPC article explaining this in detail:
https://www.aapc.com/blog/27096-initial-subsequent-sequela-encounter/ 
The basic overview is INITIAL = active treatment; SUBSEQUENT = recovery; SEQUELA = late effects.


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## Lisawills08 (Feb 15, 2019)

Thank you very much for your help! This is the first time I have had this and was second guessing myself.


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