Balloon Uterine Stent Placement During Hysteroscopic Surgery

Should you code the placement of a balloon uterine stent?

By Michella Van Antwerp, CPC, CASCC

As balloon uterine stent placement following intrauterine hysteroscopic surgery becomes more common, I hear more and more coders questioning whether they can separately code this procedure. Let’s set the record straight, right now.

Understand Use of Balloon Uterine Stents

To prevent reformation of moderate to severe adhesions and reduce uterine bleeding after hysteroscopic adhesiolysis, a balloon uterine stent (small catheter with a balloon at the end) can be placed in the endometrial cavity. Balloons designed specifically for this purpose, such as a Cook® Medical balloon uterine stent, are most often used. This stent mechanically separates the walls of the endometrial cavity to prevent adhesion reformation. The stent is usually kept in place for five to seven days to allow adequate healing of the endometrium.

For example, a patient presents for surgery due to a diagnosis of intrauterine adhesions:

The hysteroscope, which had been prefilled with a sorbitol and mannitol solution, was inserted to the level of the external os. It was advanced into the cavity under direct vision. Systematic exploration of the cavity revealed findings described above. Miniature scissors were passed through the operating port of the hysteroscope and all adhesions were lysed. Uterine architecture was now normal. Hemostasis was adequate. Sponge count was reported as being correct. The cervix was dilated to 9 mm and a small Cook balloon uterine stent was placed. Hemostasis was still adequate. Once again, the sponge counts were reported being correct. All the instruments were withdrawn and the procedure was terminated.

In this case, would placement of the balloon uterine stent be separately reported with 58579 Unlisted hysteroscopy procedure, uterus, or is it inclusive of the primary procedure?

Look to American Medical Association for Guidance

When this question was recently asked of the AMA, the response was, “… the placement of the balloon in the uterine cavity is part of the primary procedure and is not reported separately from the lysis of adhesions procedure.”

To be clear, placement of a balloon uterine stent is inclusive of the primary lysis procedure and is not separately reported. The correct reporting for our example is 58559 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method).

The supply for the stent should be reported, however. For those payers requesting “C” HCPCS Level II codes, the correct code (per the device manufacturer) is C2628 Catheter, occlusion.

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Michella Van Antwerp, CPC, CASCC, is a performance improvement analyst with the Surgical Care Affiliates coding team. She has been in the healthcare field for 17 years and has been a certified coder for 12 years, specializing in ambulatory surgery center coding and auditing. She is a member of the Reno, Nev., local chapter.

Michelle Dick
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Michelle Dick

Executive Editor at AAPC
Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.
Michelle Dick
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About Has 134 Posts

Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.

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