ED Coding and Reimbursement Alert

Question: How should I code for removal of a foreign body, vaginal, without anesthesia? The only code in CPT is with anesthesia 57415. Can we use the with anesthesia code with modifier -52 (reduced services)?

Cora Dickson
Nashville, Tenn.

Answer: Removal of an imbedded foreign body in the vagina without anesthesia should be coded using an evaluation and management (E/M) code. Using 57415 (removal of impacted vaginal foreign body [separate procedure] under anesthesia) would not be an accurate reporting of your services.

Directly beneath 57415 is the instruction: For removal without anesthesia of an impacted vaginal foreign body, use the appropriate E/M code.

Choose the level of E/M that would pertain to the degree of difficulty removing the foreign body and make sure the documentation reflects the actual site, what type of object, how it was placed, if any surrounding areas were affected and so on.

If this procedure was performed in the emergency department (ED), use 99281-99285 (emergency department visit), 939.2 (foreign body in genitourinary tract [vulva and vagina]) and an E code from the External Causes of Accidents and Injuries section of ICD-9.

Remember, E codes cannot be used without the primary diagnosis code. (For more information on E codes see the September 2000 ED Coding Alert Multiple Diagnoses and E Codes, page 71.)



Sources for Reader Questions: Jody Nau, RHIT, compliance analyst, University of Rochester; Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.; Linda Jackson, CCS-CPC, administrator/CEO, Southern Orange County Pediatric Association, El Torro, Calif. and Medicare consultant, Iowa Veterans Home, Marshall Town, Iowa; Jennifer Nelson, NCMA, CCS-P, independent coding consultant in Corinna, Maine; Lamon Willis, CPC, independent coding consultant, Lawtey, Fla.; Jan Rassier, RN, ER reimbursement coordinator for Edward Hospital in Naperville, Ill.; Charlene Endre-Day, CMA, CMM, CPC, director of professional relations for Team Physicians of Arizona Emergency Physicians, an ED group in Phoenix; Michael A. Granovsky, MD, chief financial officer, Greater Washington Emergency Physicians, a 5 physician group staffing a 24,000 visit ER in suburban Md.; John Turner, MD, PhD, medical director for documentation and coding, healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn.; and Caral Edelberg, CPC, CCS-P, president, Medical Management Resources Inc. Fla., an emergency department coding consulting firm in Jacksonville, Fla.