Ob-Gyn Coding Alert

Reader Questions:

Cervical Polyp

"Question: If while performing an annual pelvic exam, the doctor finds and removes a cervical polyp, is there a code for the removal or is it included in the office visit?

Dana M. Zona
LHS Management Company
Woonsocket, RI

Answer: There is no CPT code that specifically describes the removal of a cervical polyp because it is considered a minor procedure. Coding for it is possible, however, in one of two ways. If it is removed under colposcopic guidance, report 57452 (colposcopy [vaginoscopy]; [separate procedure]) with the preventive evaluation and management (E/M) service. Otherwise, use code 58999 (unlisted procedure, female genital system [nonobstetrical]) and submit documentation to explain the procedure."