Reimbursement Advisor

14-day 5-FU application: Reimbursement unlikely

Author and Disclosure Information


Q We are using a tampon coated with 5-fluorouracil (5-FU) cream (daily for 2 weeks) to treat a Medicare patient with highgrade vaginal lesion. Should we assign a low-level E/M code (it doesn’t take long) or is there a better procedure code?

A You will likely have trouble securing reimbursement because 5-FU can be self-administered via a vaginal applicator.

If this had been a 1-time treatment, I would advise using 57061 (destruction of vaginal lesion[s]; simple)—the lesion is being destroyed via chemosurgery. This code has a relative value unit of 3.01 when performed in the office. It is unlikely, however, that the Medicare carrier will reimburse for this level of procedure for 14 consecutive days, even if you use modifier -76 (repeat procedure by the same physician).

They might, however, allow you to bill a low-level E/M service each day, assuming you can get past the coverage guidelines for medications that can be self-administered. Are you, as the physician, personally inserting the tampon each time? If this is the case, and no other E/M services are taking place at each encounter, I would recommend billing a level 2 E/M service (99212) each day.

You might want to communicate with the carrier regarding why you are inserting the tampon rather than having the patient do it. For instance, is she unable to comply with the treatment because of age-related problems such as dexterity or senility?

Next Article: