Ob-Gyn Coding Alert

Question: A patient with a large object in her vagina presented to the emergency department (ED). The ED physician and ob-gyn attempted to remove it but failed. The ob-gyn decided to try to remove it under anesthesia -- which also failed. How should I report these failed attempts?

Nevada Subscriber

Answer: What you describe is in fact an -impacted- vaginal foreign body. Consequently, you should report 57415-52 (Removal of impacted vaginal foreign body [separate procedure] under anesthesia; reduced services) for the failed attempt under anesthesia.

You may also report the ED visit separately (using 99281-99285, Emergency department visit ...) for your ob-gyn if the ED physician does not also report this service. In that case, your physician will report an outpatient E/M service (99211-99215) instead of the ED service.

CPT says an attempt to remove an impacted object without anesthesia is an E/M service only, and you-ll base the service level on all three of the key components (history, exam and medical decision-making) for an ED service, or if you-re billing an outpatient visit, two of the three key components for an established patient. The level of difficulty in attempting to remove the object will basically be part of the examination.

Remember to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code when you report a service like 57415-52 to show that the E/M service was distinct and separate from the procedure. 

Don't forget: For the diagnosis, you-ll use 939.2 (Foreign body in genitourinary tract; vulva and vagina), and you may also want to report an E code that better explains how the patient's condition came about.