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Ob-Gyn Coding Alert

Reader Question:

Examine 57410 vs. 49000 for Exploratory Vaginal Surgery

Published on Mon Nov 07, 2011

Question: My ob-gyn performed an exploratory vaginal surgery. The patient was status post normal spontaneous vaginal delivery with continuous vaginal bleeding after a vaginal repair of laceration. The vaginal packing was in place. Should I report 57410 or 49000? New Mexico SubscriberAnswer: This depends on the approach. You should report 57410 (Female pelvic examination under anesthesia) if the ob-gyn looked only at the vagina, and of course this procedure means it was a vaginal approach. Code 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) is an open abdominal procedure.
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