Endometrial Cryoablation with Ultrasonic Guidance

[abrookner232@gmail.com]

Hello,

Can CPT code 58356 for endometrial cryoablation with ultrasonic guidance be billed if a portable ultrasound (v-scan) machine is used instead (guidance is used but it does not capture an image)? Or must an image be captured and readily available in order to bill this code? Thank you.

 

[nielynco]

Hello,

Can CPT code 58356 for endometrial cryoablation with ultrasonic guidance be billed if a portable ultrasound (v-scan) machine is used instead (guidance is used but it does not capture an image)? Or must an image be captured and readily available in order to bill this code? Thank you.

The CPT clinical vignette describes the work as follows: Connect a probe to the cryoablation console and deploy a sterile drape. Precool the machine. Place a Foley catheter and fill the bladder. Place a tenaculum on the anterior cervical lip and apply traction. Evaluate and dilate the cervical canal. Perform suction curettage. Use ultrasonography to observe and direct the cryoprobe probe. Insert the probe to the fundus and direct toward one cornu. Inject sterile saline and evaluate the uterus for air and visualization. Initiate the first freeze. Cool the cryoprobe tip temperature to -60°C. Monitor the cryozone with ultrasonography to ensure that the cryozone does not extend beyond the serosa. When this freeze is complete, initiate a heat cycle in the cryoprobe. After the tip reaches 20°C, reposition the probe and melt a path to the contralateral cornu. Inject sterile saline and initiate the second freeze. Typically two to four freezes are conducted. After all freezes are complete, remove the cryoprobe and the tenaculum. Achieve hemostasis of the cervix. Empty the patient's bladder and remove the catheter. Remove the speculum.

CPT specifies in the guidelines that image documentation is required. In the diagnostic section for ultrasound there is a statement "ultrasound guidance procedures also require permanently recoded images of the site to be localized, as well as a documented description of the localization process, with separately or within the report of the procedure for which the guidance is utilized." It is pretty clear that the images must be captured.