Ob-Gyn Coding Alert

Question: How do I code for culdocentesis? [Aspiration of fluid from the rectouterine space via a spinal needle inserted through a puncture at the fornix (apex) of the vagina. -Ed.] The presence of blood confirms an ectopic pregnancy. I cant find a code.

Practice Manager from New York

Answer: This is a great question, and once again reflects the continuous state of change of the profession. Many years ago, physicians called the procedure you described a colpocentesis, and it was added to the CPT using that language. The correct current term for the procedure is culdocentesis, but you wont find that listed in the CPT, only the prior term colpocentesis is listed. ACOG states they have been trying to get CPT to change this language for a few years now with no success. The code you are looking for is 57020, in the section for incision of the vagina. Note that it is a CPT starred procedure. This means it has no global period.

Note: When a star follows a surgical procedure code, the service listed includes only the surgical procedure, not any associated pre- or postoperative services.