Our patient comes in the office for an endometrial biopsy. The physician lists codes 58100, 57800, and 64435.
Her note reads:
Bimanual Performed, Uterine position noted to be retroverted, Speculum placed, Cleansed cervix with antiseptic, Paracervical block used(Comments: 3, 1.7cc vials of mepivicaine), Tenaculum applied to anterior lip of cervix, Tenaculum removed and hemostasis apparent, Patient tolerated procedure well, Comment: attempted to dilate cervix with os finders; unable to get into cervix at all..
Physician indicated the endometrial biopsy as a failed procedure. I would think we will not bill 58100 (endometrial biopsy). 57800 (dilation of cervix) appears to have failed so bill with modifier, don't bill? The only thing that appears to have been accomplished was 64435 (paracervical block).
Coding suggestions??
Her note reads:
Bimanual Performed, Uterine position noted to be retroverted, Speculum placed, Cleansed cervix with antiseptic, Paracervical block used(Comments: 3, 1.7cc vials of mepivicaine), Tenaculum applied to anterior lip of cervix, Tenaculum removed and hemostasis apparent, Patient tolerated procedure well, Comment: attempted to dilate cervix with os finders; unable to get into cervix at all..
Physician indicated the endometrial biopsy as a failed procedure. I would think we will not bill 58100 (endometrial biopsy). 57800 (dilation of cervix) appears to have failed so bill with modifier, don't bill? The only thing that appears to have been accomplished was 64435 (paracervical block).
Coding suggestions??