The Operative report is below. The provider is trying to bill on our system with 57500 and 58558 and the operative report is showing the 58563. My question is this Symphion hysteroscope considered 58558 or 58563?
Diagnoses:
Pre-op Diagnosis
* Abnormal uterine bleeding [N93.9] Post-op Diagnosis
* Abnormal uterine bleeding [N93.9]
Procedures:
EXCISION OF CERVICAL MASS, DILATION AND CURETTAGE HYSTEROSCOPY POSSIBLE SYMPHION
58563 - PR HYSTEROSCOPY,W/ENDOMETRIAL ABLATION
Specimens Removed:
Specimens
ID Source Type Tests Collected By Collected At Frozen? Priority Lab ID
1 Other Tissue · PATHOLOGY TISSUE REQUEST
Description: CERVICAL MASS
2 Endometrium Tissue · PATHOLOGY TISSUE REQUEST
Patient brought to the or where she was prepped and draped in the normal sterile fashion in the dorsal lithotomy position.
Bladder was drained of clear urine.
Weighted speculum was placed into the vagina.
Prolapsing cervical mass was seen protruding through the cervix.
Using curved heaney x 2 the stalk of the mass was grasped x 2
The cervical mass was transected
transfixation stitch x 2
Hemostasis was noted to be adequate following Heaney removal.
Ring forceps was used to grasp the anterior lip of the cervix.
Secondary to cervical mass cervix was already dilated.
The symphion hysteroscope was inserted into the uterine cavity and the uterine cavity was observed and noted to be relatively normal with suspicion for submucosal leiomyoma.
Using the symphion resector curettings were taken in all quadrants of the uterus.
Following symphion resection hysteroscope was removed.
Patient tolerated the procedure well without issue or complication.
Pathology will be reviewed as an out patient.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Cancer Staging: no
Diagnoses:
Pre-op Diagnosis
* Abnormal uterine bleeding [N93.9] Post-op Diagnosis
* Abnormal uterine bleeding [N93.9]
Procedures:
EXCISION OF CERVICAL MASS, DILATION AND CURETTAGE HYSTEROSCOPY POSSIBLE SYMPHION
58563 - PR HYSTEROSCOPY,W/ENDOMETRIAL ABLATION
Specimens Removed:
Specimens
ID Source Type Tests Collected By Collected At Frozen? Priority Lab ID
1 Other Tissue · PATHOLOGY TISSUE REQUEST
Description: CERVICAL MASS
2 Endometrium Tissue · PATHOLOGY TISSUE REQUEST
Patient brought to the or where she was prepped and draped in the normal sterile fashion in the dorsal lithotomy position.
Bladder was drained of clear urine.
Weighted speculum was placed into the vagina.
Prolapsing cervical mass was seen protruding through the cervix.
Using curved heaney x 2 the stalk of the mass was grasped x 2
The cervical mass was transected
transfixation stitch x 2
Hemostasis was noted to be adequate following Heaney removal.
Ring forceps was used to grasp the anterior lip of the cervix.
Secondary to cervical mass cervix was already dilated.
The symphion hysteroscope was inserted into the uterine cavity and the uterine cavity was observed and noted to be relatively normal with suspicion for submucosal leiomyoma.
Using the symphion resector curettings were taken in all quadrants of the uterus.
Following symphion resection hysteroscope was removed.
Patient tolerated the procedure well without issue or complication.
Pathology will be reviewed as an out patient.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Cancer Staging: no