Ob-Gyn Coding Alert

You Be the Coder:

Cervical Polyp Removal During Gyn Exam

Reviewed on April 21, 2015
Question: During an annual gynecological exam, the physician found a cervical polyp and removed it. The only polypectomy in the coding book that I see is 58558. Should I use this code, or is there a better alternative?  California Subscriber  Answer: For this procedure, you should use 57500 (Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]), which you should report whether the physician removed a lesion on the cervix (which can be a polyp) or performed a biopsy.   Note: You would report 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) when the ob-gyn removes a uterine polyp via the hysteroscope. Therefore this code does not fit this situation.   Remember: You should add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the annual exam code (99384-99386 for new patients, or 99394-99396 for established patients) you report to indicate that the preventive service was separate and significant from the polyp removal. Also, don’t forget to link 622.7 (Mucous polyp of cervix) to 57500. In ICD-10, your diagnosis code will be N84.1 (Polyp of cervix uteri) instead.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more


Other Articles in this issue of

Ob-Gyn Coding Alert

View All