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Vaginoscopy with Biopsy and Fulgeration

David Posted Wed 13th of April, 2016 15:33:53 PM
My physician had a patient whose bladder had been removed. He used the cystoscope to examine her vagina and biopsy and fulgerate an area of the vagina that had been actively bleeding. How do I code this procedure?
SuperCoder Answered Thu 14th of April, 2016 02:56:18 AM
As per NCCI (National correct coding Initiative), Control of bleeding during an operative procedure is an integral component of a surgical procedure and is not separately reportable. Postoperative control of bleeding not requiring return to the operating room is included in the global surgical package and is not separately reportable. However, control of bleeding requiring return to the operating room in the postoperative period is separately reportable utilizing modifier 78.
David Posted Thu 14th of April, 2016 10:07:37 AM
The vaginoscopy with biopsy and fulgeration was the surgical procedure itself. This was a planned surgery. How do I code it?
SuperCoder Answered Tue 19th of April, 2016 06:49:29 AM
Please use CPT code 57023 and CPT code 57421

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