Urology Coding Alert
57421 Describes Colposcopy With Biopsy
Question: My physician saw a patient whose bladder had been removed several weeks before. Because of vaginal spotting he used the cystoscope to examine her vagina and to biopsy and fulgurate a red granular area of the vaginal wall that had been bleeding. This was an unplanned surgery. How do I code this procedure?
Louisiana Subscriber
Answer: Report procedure code 57421 (Colposcopy of the entire vagina, with cervix if present; with biopsy[s] of vagina/cervix) for the biopsy and fulguration of the vagina. Since this procedure occurred in the global period of the bladder removal (cystectomy) and appears to be a complication of the previous surgery, append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). Include diagnosis N99.820 (Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure).
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