You Be the Coder:
Hysteroscopy D&C With Uterus Perforation
Published on Wed Jun 17, 2009
Question: My ob-gyn performed the following procedure: Hysteroscopy dilation and curettage (D&C) with a diagnosis of menorrhagia and irregular menses, a diagnostic laparoscopy for the evaluation of the uterine perforation, and an exploratory laparotomy with repair of the uterine perforation.How should I report this? Colorado Subscriber Answer: If this was a Medicare patient, you can bill nothing extra when the surgeon fixes a problem he created. Other payers may reimburse, but you should look at why the ob-gyn could not repair the uterus via the laparoscope. This means you would report only 58520 (Hysterorrhaphy, repair of ruptured uterus [nonobstetrical])-- that is, if you are able to report this at all. Watch out: Because your note describes a converted procedure, you should not report diagnostic code 49320 (Laparoscopy, abdomen, peritoneum, and omentum,diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and the surgery code 58520. That is, [...]
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