Question: A patient came in the other day for her routine exam, including her Pap and pelvic, and a complaint of some sporadic vaginal bleeding. During the exam I found a couple of retained sutures in the front part of the superior vaginal vault. These had formed an inflammatory granuloma causing some bleeding. The patient had a hysterectomy four years ago.
I spent at least 25 minutes trying to remove these difficult-to-get-to sutures without causing anymore problems. They were successfully removed. I’m now being told that there is no code for this procedure. Surely there is a way to get something for my time and skill?
Answer: There is no code for suture removal, and the only code for vaginal foreign body removal (57415 — removal impacted vaginal foreign body) requires anesthesia. It sounds like you just got the sutures out, likely taking care not to excise any tissue. It also does not sound like it was encysted, so that eliminates 57135.
There is a note under 57415 in the CPT manual that states “for removal without anesthesia of an impacted vaginal foreign body, use the appropriate E&M code.”
This presents a difficulty given that you already had an E&M going, either preventive, problem-oriented, or both. The additional exam involved is not likely to get you much in terms of moving the code to a different level, assuming there is a problem-oriented code. Likewise, the history isn’t going to change much on terms of code levels. If you had a 99213 going previously, this could move it towards a 99214.
I would suggest using the add-on code 99354 for prolonged services, but that requires a minimum of 30 minutes and this took only 25 minutes — or was that a guestimate? Maybe you would want to revisit the “at least” part of your question. Do remember this qualifier if something like this arises again and takes that amount of time.
What this seems to leave us with is not much. There does not appear to be a CPT for unlisted procedure in the vagina. You could try 57200-52, the code for placing sutures to repair an injury of the vagina, with the 52 modifier to indicate that this procedure is a lesser version of that one — in fact, the reverse. Some might consider this a stretch, but at least it opens the dialog with the payer. Let us know how it turns out!
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at [email protected] or [email protected].
This question originally appeared in the April 2010 issue of Physicians Practice.