Clinical Context
A typical patient is a woman presenting to the emergency department or same-day surgical unit after insertion of a foreign object into the vagina that cannot be removed in the clinic due to patient discomfort, mucosal entrapment, or deep impaction. Examples include retained intravaginal devices, fractured condom or tampon fragments, small toys, or organic material that became lodged in the vaginal fornix. Initial evaluation includes history, focused pelvic exam, and bedside attempts at removal with topical or local anesthesia. If the object is tightly wedged, embedded in the vaginal wall, or the patient is unable to tolerate manipulation, the provider schedules removal in an operating room or procedure suite under general anesthesia or regional anesthesia (spinal/epidural) — i.e., anesthesia other than local. The workflow typically involves preoperative consent, anesthesia evaluation, patient positioning in dorsal lithotomy, sterile preparation, use of vaginal speculum and appropriate grasping or extraction tools (forceps, curettes, suction), possible limited sharp dissection if embedded, hemostasis, and postprocedure inspection for mucosal or deeper injury. Postoperative documentation includes the foreign body description, estimated duration of impaction, anesthesia type, instruments used, any complications, and discharge instructions. Usual sites of service are the hospital operating room, ambulatory surgery center, or emergency department procedure room with anesthesia support.
Coding Specifications
| Modifier | Description | When to Use |
|---|
23 | Unusual anesthesia | Use when procedure is performed under general anesthesia for a normally local procedure due to need for immobility or patient distress. |
22 | Increased procedural services | Use when removal required substantially greater effort or complexity (extensive dissection, prolonged time) than typical.
52 | Reduced services | Use when the procedure was partially completed or aborted and full procedure not performed.
53 | Discontinued procedure | Use when procedure stopped due to patient condition or intraoperative findings prior to completion.
59 | Distinct procedural service | Use to indicate a separate and distinct procedure when multiple procedures are billed on same day.
76 is not in the provided modifier list so not included | Data not available in the input | Data not available in the input
62 | Two surgeons | Use when two surgeons from different specialties jointly perform the procedure.
80 | Assistant surgeon | Use when an assistant surgeon is documented and required for the case.
AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant-at-surgery | Use when an advanced practice clinician provides documented assistant-at-surgery services.
26 | Professional component | Use for reporting the professional component when separate technical services are billed (rare for this code).
51 | Multiple procedures | Use when removal is billed with other procedures and reduced payment for additional procedures applies.
53 | Discontinued procedure | Use when procedure terminated due to emergency or patient instability prior to completion.
63 | Procedure performed on infants less than 4 kg | Use when applicable to neonates (rare for this procedure).
59 | Distinct procedural service | Use when another unrelated procedure is performed the same day and needs separation.
Associated Provider Taxonomies
| Taxonomy Code | Specialty | Notes |
|---|
207V00000X | Obstetrics & Gynecology | Most common specialty performing vaginal foreign body removals. |
207UH0000X | Urogynecology | Manages complex pelvic floor involvement or embedded objects near supports.
208800000X | General Surgery | May be involved for surgical extraction in complex cases.
163WL0500X | Emergency Medicine | Often initiates care and may perform bedside attempts or coordinate OR transfer.
366A00000X | Anesthesiology | Provides general or regional anesthesia required for the procedure.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
N76.0 | Acute vaginitis | Common cause of vaginal discomfort and may coexist with foreign body; inflammation can complicate removal. |
N76.1 | Subacute and chronic vaginitis | Chronic inflammation may be associated with retained foreign material causing persistent symptoms.
N89.8 | Other specified noninflammatory disorders of vagina | Used when a retained object causes noninfectious mucosal changes.
T19.8X1A | Foreign body in other specified parts of digestive tract, initial encounter (placeholder) | No exact vaginal foreign body code in T-codes; this entry is not appropriate — Data not available in the input
S31.81XA | Laceration of other and unspecified parts of external female genitalia, initial encounter | Report when mucosal or vulvar laceration occurs during removal.
R10.9 | Unspecified abdominal pain | May be present when pelvic discomfort or referred pain accompanies a vaginal foreign body.
Z76.2 is not relevant and not in provided list | Data not available in the input | Data not available in the input
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
01999 | Unlisted anesthesia procedure | Used to report anesthesia services not described by existing anesthesia codes when unusual anesthesia is required. |
57110 | Excision of lesion of vulva; simple (eg, cyst, polyp) | May be performed if removal requires excision of adjacent vulvar tissue.
57420 | Removal of foreign body from female genital tract; vaginal approach, requiring operating room or anesthesia | Alternative or related code for vaginal foreign body extraction requiring more extensive operative management.
99024 is not an appropriate CPT surgical code and is not in the provided related list | Data not available in the input | Data not available in the input
76930 | Ultrasonic guidance for needle placement | May be used if imaging guidance assists localization prior to extraction.
51701 | Catheterization, simple, most common | May be performed if urinary catheterization is needed perioperatively for bladder drainage or visualization.