Ob-Gyn Coding Alert

Question: My ob-gyn documented the following procedure:

Dilation and curettage/hysteroscopy/polypectomy/excision of cervical mass. I’m not sure of the code for the excision of cervical mass. The following is from the op-report: The hysteroscope was then removed from the uterus and fluid deficit was 105ml. An endometrial curettage was then performed. Attention was then turned to remove the cervical masses. The 1 cm ectocervical polyp was grasped with the pickup and removed using Metz scissors. Attention was then turned to remove the larger cervical mass. Using a 2.5x 1cm loop, the mass was excised in one pass using LEEP, bed of the excision site was cauterized.

I was going to use 58558 for the first part of the surgery (D&C/hysteroscopy/polypectomy). What should I report?

Georgia Subscriber

Answer: Yes, you should code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C).

Code 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) would be correct for the cervical mass. The fact that he used the LEEP does not matter — unless he was performing a conization or doing colposcopy with the removal, which he did not. The Correct Coding Initiative (CCI) does not bundle it into 58558.