Wiki Endometrial Bx w/ dilation

[maggiedinaz@yahoo.com]

Hello,
Does anyone know what is the appropriate code for an endometrial dx with dilation?

The Dr submitted 58100- endometrial bx + endocervical bc w/o dilation and 57800 for the dilation. Insurance denied as bundled. The doc had to dilate the patient due to cervical stenosis.

I reviewed other codes and the only other possibility I found was 58120 D&C, diagnostic and/or theraputic (nonob). coding tip states this includes bx whether being performed with a curette or another method.

Doc states he did not curettage just dilated and took a endometrial dx with A Pipelle endometrial biopsy brush.

 

[Lorri62t]

Endometrial Dilation with Dilation

You are correct with the 58100 and 57800 but you need a modifier on the 2nd one. I always post the code with the higher RVU first and the second one with the modifier -51. You can also charge an Office Visit (E & M) code with modifier -25 if done in the office. If you have to, send notes stating why dilation was necessary. If it was Cervical Stenosis or other that required the Cervical Dilation, be sure and attach that to the Dilation code as the primary.

D & C is not the same thing and cannot be used in your case.

Hope this helps

 

[maggiedinaz@yahoo.com]

Thanks