Ob-Gyn Coding Alert

Reader Question:

Biopsy Is Included in Excision

Question: Our patient had a total abdominal hysterectomy, bilateral salpingo-oophorectomy and cervical biopsy during the same surgical session. Can I report both 58150 and 57455?

Hawaii Subscriber

Answer: In this situation, submitting both 58150 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) and 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the  cervix) would be appropriate only if the ob-gyn performed the hysterectomy and biopsy during different surgical sessions. Otherwise, you should report only 58150 because this covers all the procedures mentioned in the question.

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