Wiki biopsy 58100

[RaiAnne]

I am looking for guidance on billing 58100 endometrial biopsy; the lab did not have an adequate sample. Can I still bill for the procedure? And when the patient returns for a repeat biopsy; can that be billed?

Thank you

 

[bgrasson]

i would have just billed an E/M for the first procedure or bill 58100 with mod 52 then try to bill 58100 again for the repeat.

 

[thomas7331]

I disagree. Unless the documentation supports an E/M service or a reduced service on the first procedure, neither of those options would be correct.

If the documentation shows that the patient had to undergo the full procedure twice, then you can and should code for it twice, unless your employer instructs you otherwise due to some kind of extenuating circumstances (e.g. if the provider was somehow at fault or responsible for the procedure needing to be repeated, they may elect to repeat it at no cost to the patient and/or payer).

 

[csperoni]

I'm with Thomas. I know sometimes when the physician is performing the EMB, they are unable to properly perform it, and then -52 would be appropriate. If that was not the case, the first should be billed as whatever was performed. Whether just 58100 or E/M along with 58100 if documented.
The repeat EMB would likely just be 58100 unless the patient presented with other issues to be addressed, and then E/M with 58100.