D&C of uterine hematoma

[ltingle1]

One of our MDs did a dilation and curettage and evacuation of uterine hematoma. I was going to code 58120, would that cover the evacuation of hematoma as well?

"The patient was placed on the table in the supine lithotomy position. She was prepped with hibiclens and draped in the appropriate sterile manner. The patient had voided prior to the procedure. A speculum was placed in the vagina. The cervix was visualized . A tenaculum was placed on the anterior lip of the cervix for traction. A paracervical block was not placed.

The cervix was dilated under direct ultrasound guidance using the smallest dilator. There was significant stenosis at the internal os. Eventually a #7 was able to be placed and then significant amount of brown blood was evacuated. The entire endometrial cavity was evacuated under US guidance. A brief curettage was done with a small sharp curet to test for any endometrial pathology. This will be sent to pathology."

Thanks,
Lauren

 

[csperoni]

I would consider the evacuation of the hematoma part of the D&C. I might query the provider to see if -22 might be warranted. If the op note is exactly as above, I would not assign -22.
Also, don't forget to code your ultrasound guidance!