ED Coding and Reimbursement Alert

Question: A 33-year-old non-pregnant woman presented to the ED with periumbilical pain after two days of heavy bleeding. The bleeding had decreased in the past two days, but the abdominal pain had increased to a 7 on a 10 scale. On examination, the physician discovers a large "clot" in the vaginal canal, which she removes with a clamp. Lab results report that the clot was "largely fibrinated blood and debris." The physician diagnosed vaginal bleeding. Is there a procedure code for the removal of the polyp (I was thinking 58558), or would I consider the clot removal when determining the E/M level?

Georgia Subscriber

Answer: You should consider the work to remove the clot when choosing your ED E/M code for this service (99281-99285). Remember to append 789.05 (Abdominal ED Coding Alert/2009, Vol. 12, No. 12 Get CPC® certified in 4 days -- CodingCert.com Page 95 pain, periumbilic) and 623.8 (Other specified non inflammatory disorders of vagina) to the E/M code to represent the patient's pain and vaginal bleeding, respectively.

Code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C) does not describe the procedure your ED physician performs in this case; this was a non-surgical polyp removal. In fact, it would be exceptionally rare for this type of surgery to occur in the ED setting.