Ob-Gyn Coding Alert

Question: I’m looking for some assistance on the below procedure note. I’m leaning toward an office visit, since I can’t find a CPT^® procedure code. The procedure is as follows:

“Procedure - Separation of labial agglutination
Preoperative diagnosis - labial agglutination
Postoperative diagnosis- labial agglutination

“The area was cleaned with Betadine and then local numbing cream was applied and covered with sterile gauze for 18 minutes. 

“The area was checked after this time and found to be adequately numb for the procedure. Gently applying pressure with a sterile Q-tip on both sides of the middle, and opening was made to about 2 cm. At that point patient started getting uncomfortable so the procedure was concluded, and was advised to use Premarin cream as before twice a day. Complications none. 

“Patient tolerated the procedure fairly well.” 

What should I report?

Kentucky Subscriber

Answer: You should most likely code an evaluation and management (E/M) code (99202-99215) instead of an unlisted procedure code. Look at the documentation to see if using total time will get you the highest level of service.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor