Wiki Exam Under Anesthesia for a 3year old

[meeka8@hotmail.com]

Pt. is a 3yr old female who had a vulvar straddle injury. The Dr. did an examination under anesthesia. He checked the vulvar and made sure hymen was in tact and irrigated with normal saline.

Is there a code for EUA for children? If not, would hospital exam code be appropriate?

 

[Cynthia Hughes]

exam under anesthesia

Look to code 57410. This requires more than local anesthesia.

 

[meeka8@hotmail.com]

Look to code 57410. This requires more than local anesthesia.

General anesthesia was used, but the provider did not examine the patient internally as she is only 3 yrs old. I didn't think this code was appropriate.

 

[Cynthia Hughes]

exam under anesthesia

My apologies, my previous answer was incomplete.You could append modifier 52 to indicate that the complete procedure was not performed. Alternatively, you could report an unlisted procedure and include a narrative description of the service. There is also code 99170 but this includes a magnified examination using colposcopy and is usually performed for suspected abuse. Either way, if you append modifier 52 and provide a narrative describing the procedure performed, the claim will include the information necessary for the payer to make a determination of benefits. Cindy