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Wiki EMB w/mass found

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carriganm

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Central Point, OR
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Help! I have no idea how to code this one.

Endometrial Biopsy:
Risks, benefits and indications for endometrial biopsy procedure fully reviewed. Patient questions answered. Informed consent obtained.
Speculum placed into vagina.
There was a mass of tissue bright red extending out of the cervix. I did attempt to go around this mass but I was not able to so I took a piece of a mass to sent for pathology and the rest of the EMB was aborted.

1. Postmenopausal bleeding -
We attempted the EMB today.
There was a mass of tissue bright red extending out of the cervix. I did attempt to go around this mass but I was not ale to so I took a piece of a mass to sent for pathology and the rest of the EMB was aborted. Patient was give post-procedural instructions.
Patient will be notified of the pathology.
N95.0: Postmenopausal bleeding
 
0
It does seem like the mass was possibly from the endometrium. If so, then I would code as endometrial biopsy 58100.
If the mass was a cervical mass, or if it's not clear it was endometrial, then I would code as cervical biopsy 57500.
I don't recall seeing prior official advice here or from ACOG with that scenario. If your physicians are ACOG members, you could always submit a coding request.
 
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