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Wiki Failed IUD insertion due to concern of perforation

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dalila10

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Franklin Square , NY
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Good morning,

I am stuck between 2 diagnosis and hope someone can assist.

Scenario: Patient was seen for an IUD insertion but after 2 attempts the provider indicated:

" There was some resistance at endocx. After overcoming resistance, the sound was gently advances and advanced to 13 cm without meeting any resistance. Procedure abandoned 2/2 concern for false passage, uterine perforation."

I would use the T83.39XA because the provider indicated uterine perforation and unsure if and when to use the Z53.8 code and if this would be the time to use it.

I also used 58300 Modifier 53

Hope someone can assist!
 
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