Health Information Management

Q&A: Coding removal of a Bartholin's gland cyst catheter in the ED

HIM Connection, November 30, 2010

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Q: What code should I report for a patient who presents to the ED for removal of a Bartholin’s gland cyst catheter? Should I report ICD-9-CM codes V58.82 (fitting and adjustment of non-vascular catheter, not elsewhere classified) and 98.1x (removal of intraluminal foreign body from other sites without incision)?

A: I need more details before I can provide an exact answer. In general, EDs provide outpatient services. This means coders typically report CPT® codes—not ICD-9-CM volume three procedure codes. However, some third-party payers do require them. I will address both code sets.
 
You mentioned reporting ICD-9-CM procedure code 98.1x. This is problematic because it’s an invalid code as stated and requires a fourth digit. Second, this code denotes removal of intraluminal foreign body from other sites without incision. A catheter is not a foreign body—it is a therapeutic device. Therefore, I suggest considering code 97.79 (nonoperative removal of therapeutic device from genital tract).
 
An incision and drainage (I&D) to treat a Bartholin’s gland cyst begins with a small incision in the cyst to allow it to drain, followed by the insertion of a catheter to allow complete drainage. The catheter may stay in place for up to six weeks and fall out on its own or be removed by a physician.
 
The service to remove the catheter is included in the CPT procedure code for the I&D (i.e., 56420, incision and drainage of Bartholin’s gland abscess). If the physician who performed the I&D and the placement of the catheter is not the same physician doing the removal (as in this case, where only the removal is being performed in the ED), you should append modifier -52 (reduced service) to the procedure code (i.e., 56420-52, incision and drainage of Bartholin’s gland abscess, reduced service), and provide documentation to explain the situation.
 
Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL answered this question, which originally appeared in the November issue of Briefings on Coding Compliance Strategies.



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