Ob-Gyn Coding Alert

Question: My ob-gyn documented "Exam under anesthesia, incision and drainage of left vulvar abscess, viral cultures, insertion of Foley catheter." Which code should I use?


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Answer: Payers generally do not reimburse separately for the exam under anesthesia (EUA) when you report a surgical procedure. Because the incision and drainage (I&D) is an external procedure and the EUA is an internal exam, however, your payer might reimburse for this. Just be sure you include the reason for the EUA (which would not be the same diagnosis as for the abscess).

You should report 56405 (Incision and drainage of vulva or perineal abscess) for the I&D. You won't find a code for taking cultures, but you could possibly report for handling the specimens using 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory).
 
The Foley insertion (51702, Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) will only be paid separately if you have a medical indication for doing so, other than as part of the I&D procedure. In fact, the American College of Obstetrics and Gynecology (ACOG) coding manual indicates that the procedure includes obtaining cultures and inserting a catheter when indicated.