Know When to Report a Hysteroscopy Code
Question: I’m not sure what codes to assign for the procedure listed below because a portion of the procedure was performed prior to the introduction of the hysteroscope. Here is the procedure: Description of Procedure: The patient was taken to the operating room. General anesthesia with an LMA was administered without difficulty. She was prepped and draped in the usual sterile fashion in the dorsal lithotomy position with her legs in allen stirrups. The bladder was straight catheterized. A surgical pause was performed. A speculum was placed, and the mass was able to be visualized and palpated prolapsing through the cervix into the vagina. The stalk was broad based, about 2cm. The mass/fibroid was grasped with a tenaculum. The stalk was tied off with a free tie suture. The fibroid was then cored out until it was resected to the suture. The hysteroscope was inserted and then clamped shut around the camera with allis clamps. There was noted to be a long wide stalk from the fibroid attached to the fundus. There was also some separate polyps and some thickened endometrium in one area. The myosure was used to resect all of this. All tissue was sent to pathology. All instruments were removed. The cervix was hemostatic. The patient was awakened and transferred to recovery in stable condition. Can you help? Connecticut Subscriber Answer: For this procedure, you’ll assign 58561 (Hysteroscopy, surgical; with removal of leiomyomata). While the physician performed a portion of the procedure before using the hysteroscope, you’ll use the hysteroscopy code that includes all the work completed. If the provider uses a hysteroscope at any time during an operative session at which a surgical procedure is performed inside the uterus and that procedure has a code that describes it, you bill the appropriate hysteroscopic procedure code rather than separate diagnostic or non-hysteroscopic codes. In this case, 58561 is the correct code choice because it covers the fibroid removal and use of the hysteroscope. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
