Ob-Gyn Coding Alert

You Be The Coder:

Cerclage Removal Under Anesthesia

Question: If an ob-gyn places a cervical cerclage during pregnancy, how can we code the cerclage removal if the doctor performs it in the office with only local anesthesia? Second, if the physician removes the cerclage with an epidural in the hospital, how should I report that?

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Answer: When the ob-gyn places the cerclage (59320, Cerclage of cervix, during pregnancy; vaginal), most carriers assume the removal is an integral part of the procedure because the physician must eliminate the cerclage prior to delivery. Consequently, they generally won't reimburse for cerclage removal performed in the office.
 
On the other hand, if the ob-gyn performs the removal using a regional block or general anesthesia, you should report 59871 (Removal of cerclage suture under anesthesia [other than local]). Keep in mind, however, that some payers will not pay for the suture removal unless the documentation shows that the removal was difficult and not simply cutting the sutures, even when done under a regional block.
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