Wiki vaginal polyp removal

[rleif1sun]

pt was found to have vaginal polyp. provider tied string around stalk of polyp to d/c blood flow and then cut with surgical scissors and sent for biopsy.
can I bill CPT 57100 or is that only for partial removal?

 

[csperoni]

This does sound more like excision of a vaginal polyp vs a vaginal biopsy.
Unfortunately, there is not a code specifically for vaginal polypectomy. When I have a situation like that, if the procedure was very quick and minor, I would consider it bundled with the office visit. If it is more extensive, I would bill with an unlisted. A comparison for the unlisted might be 57100 or excision benign lesion genitalia 11420-11426.

 

[natashalage]

Hello, I was following on coding the excision of Vaginal polyps for my learning. There are other posts here on the same topic- Vaginal polyps. In this OBGYN forum, I saw recommendations to use Unlisted CPT and compare it with either 11420- or 57100/5- Bx of vaginal mucosa. But today, my coworker received the response from ACOG advising us to code it ( the case is below) as 57135-excision of cyst or tumor (N84.2 is also listed under this CPT). I was surprised but now I will make a revision of my notes. I wanted to share this findings with all of you and I will also post this answer on other 'Vaginal polyp' posts.

 

[csperoni]

Hello, I was following on coding the excision of Vaginal polyps for my learning. There are other posts here on the same topic- Vaginal polyps. In this OBGYN forum, I saw recommendations to use Unlisted CPT and compare it with either 11420- or 57100/5- Bx of vaginal mucosa. But today, my coworker received the response from ACOG advising us to code it ( the case is below) as 57135-excision of cyst or tumor (N84.2 is also listed under this CPT). I was surprised but now I will make a revision of my notes. I wanted to share this findings with all of you and I will also post this answer on other 'Vaginal polyp' posts.
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Thank you for the additional information! If that is ACOG's recommendation, I would consider it for the future, but would take each on a case-by-case basis.
The full description for 57135 is below, and I would still hesitate to use it for the original post. I interpret the original question as a vaginal polyp attached by a thin stalk that is snipped with scissors, and did not require sutures. The example you have seems a bit more involved.
57135 Excision of vaginal cyst or tumor
In this procedure, the provider surgically removes a cyst or tumor in the vaginal wall. This is a vaginal approach surgery.
Clinical Responsibility
The provider administers local anesthesia. The patient is in the dorsal lithotomy position. He cleans the area of the cyst with plain water or dilute vinegar, and the provider carefully examines the cyst/tumor area for excision under local anesthesia. The provider then makes an incision in the vaginal mucosa over the cyst or around the tumor. He excises the whole semisolid material, closed sac, of the cyst or fully excises the vaginal tumor along with supportive healthy tissues around the tumor. He may send a cyst sample to the laboratory for examination. Once the provider successfully excises the cyst or tumor, he closes the incision with absorbable sutures. Lastly, the provider may pack the vagina with bleached cotton cloth.

 

[nielynco]

Thank you for the additional information! If that is ACOG's recommendation, I would consider it for the future, but would take each on a case-by-case basis.
The full description for 57135 is below, and I would still hesitate to use it for the original post. I interpret the original question as a vaginal polyp attached by a thin stalk that is snipped with scissors, and did not require sutures. The example you have seems a bit more involved.
57135 Excision of vaginal cyst or tumor
In this procedure, the provider surgically removes a cyst or tumor in the vaginal wall. This is a vaginal approach surgery.
Clinical Responsibility
The provider administers local anesthesia. The patient is in the dorsal lithotomy position. He cleans the area of the cyst with plain water or dilute vinegar, and the provider carefully examines the cyst/tumor area for excision under local anesthesia. The provider then makes an incision in the vaginal mucosa over the cyst or around the tumor. He excises the whole semisolid material, closed sac, of the cyst or fully excises the vaginal tumor along with supportive healthy tissues around the tumor. He may send a cyst sample to the laboratory for examination. Once the provider successfully excises the cyst or tumor, he closes the incision with absorbable sutures. Lastly, the provider may pack the vagina with bleached cotton cloth.

I completely agree with your assessment on this.