fractional D&C, attempted hysterscopy

Jamie Dezenzo

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Mishawaka, IN
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Hello all and TGIF!!!!!!!!!!

A bimanual examination was performed. The uterus was anteverted, freely mobile, small without adnexal masses. A weighted speculum was inserted into the vagina. The anterior lip of the cervix was grasped with a tenaculum. There was a moderate amount of cervical stenosis and initially I was unable to pass the uterine sound. The hysteroscope was utilized to visualize the path of the endocervical canal and using a small probe the endocervical canal was then progressively dilated to at least allow passage of the small uterine curette. The endocervical canal was then curetted, and a minimal amount of tissue was present with this. The uterine cavity was curetted. There was some smooth tissue present but nothing that was either thickened or suspicious.

With completion, attempts were not made to dilate further to avoid the possibility of perforation. The procedure was terminated. All instruments were removed. Compression of the uterus was carried out.

per doctor query due to cervical stenosis hysterscope not done, used only for placement of dilator, never got in cavity.

My question is still 58558 and to still use 74 modifier or 58120?

THANKS!
Jamie
 

bench

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The way I see it should be 58558-74 since that was the planned procedure. Also supplies and equipments must already be prepared in the OR.
 
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