Wiki E/M code with IUD removal?

[cbeste]

I would greatly appreciate thoughts on coding the following visit. A patient came in with various symptoms she felt were related to insertion of her IUD several weeks prior, including pelvic pain and burning with urination. The doctor took a chlamydia culture, removed her IUD, and coded for both a 99213 visit and a 58301 for removal of the IUD. In this instance, is an evaluation and managment code in addition to the IUD removal code appropriate? Documentation included a detailed description of her symptoms and the exam consisted of vital signs, general appearance, and a description of the IUD removal process. There was no discussion of the thinking behind ordering the chlamydia test--there is just evidence that it was taken and sent to the lab. I'm not sure if a "significant, separately identifiable evaluation and management (E/M) service" is supported.

 

[HOLLYGIFFIN]

I would like to see the actual report. If the patient specifically came for evaluation of the symptoms and not specifically the removal of the IUD, then the E&M is separate. The doctor had to evaluate all the conditions (pain, burning) to determine the origin, which may or may not be related to the IUD (hence the culture sent off). So that E&M was performed prior to the decision to remove the IUD from what I am reading. But again, I would want to see the report with the assessment and plan.

Holly Pettigrew, CPC, CPC-H
Physician Coding Auditor