Wiki Postpartum removal of mass in cervical os

[Rita B. Conley]

This patient had heavier than normal bleeding about five weeks PP. On exam the provider found a "mass" coming through the cervix. She grasped with ring forceps and removed. The cervix remained dilated 1-2 cm with fairly brisk bleeding, so two scopettes were inserted and held in placed to control bleeding.

I cannot find a CPT code that fits. A colposcope wasn't used, no instrumentation other than the above.

Can someone point me in the right direction, or is this a case where you'd use an unlisted code?

 

[ajs]

This patient had heavier than normal bleeding about five weeks PP. On exam the provider found a "mass" coming through the cervix. She grasped with ring forceps and removed. The cervix remained dilated 1-2 cm with fairly brisk bleeding, so two scopettes were inserted and held in placed to control bleeding.

I cannot find a CPT code that fits. A colposcope wasn't used, no instrumentation other than the above.

Can someone point me in the right direction, or is this a case where you'd use an unlisted code?

That is all going to be part of the E/M service for that day, and you can bill an E/M code with the 24 modifier to indicate this was outside the normal post partum care.