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Well Woman Exam under Anesthesia

Bridget Posted Mon 25th of February, 2019 14:04:12 PM
My provider did a Annual Exam under Anesthesia to include: Vaginal exam with pap smear, physical exam of neck, heart, lungs, breast, abdomen, genitourinary, skin. Also while the patient was under anesthesia the provider inserted a Mirena IUD. Can you please advise of the correct cpt codes to bill for these services?
SuperCoder Answered Tue 26th of February, 2019 03:02:42 AM

Hi Bridget,


Thanks for your question.


When the patient undergoes an annual visit and an IUD insertion at the same encounter, then you should report codes for both services. For wellness exam, you may choose your code from 99381-99397 based on the type of visit and the age of the patient. Add modifier 25 to a wellness visit code (99381-99397). For IUD insertion, you may report code 58300 (Insertion of intrauterine device (IUD)).


Please feel free to write if you have any question.



Bridget Posted Wed 06th of March, 2019 10:46:05 AM
The exam was done under anesthesia does that change the cpt codes for our GYN provider?
SuperCoder Answered Thu 07th of March, 2019 06:15:54 AM
These codes do not say anything about anesthesia. This means if patient is uncomfortable, a local anesthesia may be applied. So you may bill the code even if this is done under anesthesia.
Please let us know if you face any problem.

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