Ob-Gyn Coding Alert
Pap Smears Under Anesthesia
Question: Patient had a vaginal exam under anesthesia with Pap smear. Would I code just 57410, or would I code 57410 with 99395? Texas Subscriber Answer: You should report only 57410 (Pelvic examination under anesthesia (other than local)). You should only report 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/ diagnostic procedures, established patient; 18-39 years) if performed. Just because a Pap smear was done does not mean a comprehensive preventive medicine evaluation was done at the same time or on the same day.
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