Ob-Gyn Coding Alert

You Be the Coder:

Double Cervices? Have Strong Documentation to Use This Modifier

Question: I have a physician who did two colposcopies of the cervix on a patient with duplicated cervices. Coding edits do not allow me to bill 57452 with 57455. If I use the secondary diagnosis Q51.820 (Cervical duplication), do you think that would help get the claim paid for the two colposcopies, or can we simply only bill the one?

Ohio Subscriber

Answer: This is a permanent Correct Coding Initiative (CCI) bundle that does not allow for separate coding under any circumstances. Therefore, you should code 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix) with a modifier 22 (Increased procedural service) and be sure to include the Q51.820 as your diagnosis.  Make sure the provider has clearly documented each of the colposcopic exams separately. And of course, you will want to charge more for this procedure (equivalent to your normal charge for 57455) plus 50% of your normal fee for 57452 (Colposcopy of the cervix including upper/adjacent vagina). 


Other Articles in this issue of

Ob-Gyn Coding Alert

View All