If a physician performed a female pelvic examination under general anesthesia, you should code for the procedure using an appropriate code from the female genital system subsection of the surgery chapter of the CPT manual. If the physician performed a pelvic examination without general anesthesia, from what chapter or subsection of the CPT manual should you code?

Question

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You should code this service using information from the evaluation and management chapter of the CPT manual. A pelvic examination without anesthesia should be coded as part of the regular evaluation and management service. This information can be found in the evaluation and management chapter. If the patient needed a pelvic examination under general anesthesia, it should be coded as a service greater than an E&M service and reported using code 57410.

If a Physician Performed a Female Pelvic Examination Under General