Hysterosalpingogram with selective catheterization

sukalyan

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Procedure: hysterosalpingogram with selective catheterization.
Indication: infertility.
Complications: none.
Anesthesia: none.
Contrast: Ultravist 300, 30-ml.

Fluoroscopy time: 94 seconds.

Immediately prior to the procedure, a urine pregnancy test was
performed.
Urine pregnancy test result: negative.

Procedure description: The patient was placed in lithotomy
position and a vaginal speculum was inserted. After cleansing the
external os with Betadine solution, the cervical os was cannulated
with a 7F hysterosalpingography catheter. The catheter balloon was
inflated and contrast injection was performed with fluoroscopic
control. There was opacification of the uterine cavity. There was
no opacification of the right fallopian tube. There was no
opacification of the left fallopian tube. The balloon was then
deflated and catheter was removed. A 5F Berenstein catheter was
then used to perform selective catheterizations. Selective
contrast injections were performed with the catheter positioned at
the junction of the right cornual portion of the uterine cavity an
right fallopian tube and left cornual portion of the uterine
cavity and left fallopian tube. The catheter was removed. The
patient tolerated the procedure well.

Findings: The size and shape of the uterine cavity was normal. The
uterine cavity was displaced toward the right hemipelvis. There
was opacification of the right fallopian tube. The right fallopian
tube was normal in course and caliber with free peritoneal
spillage. There was no opacification of the left fallopian tube,
despite selective catheterization.

IMPRESSION:
1. Normal uterine cavity. Uterine cavity displaced toward the
right hemipelvis.
2. Normal appearing left fallopian tube with free peritoneal
spillage. Selective catheterization was required to achieve
opacification of and spillage from the right fallopian tube.
3. Proximal left fallopian tube occlusion, despite selective
catheterization.

Fluoroscopically-guided guidewire recanalization of the left
fallopian tube may be considered, if indicated.
catheterization.

Fluoroscopically-guided guidewire recanalization of the left
fallopian tube may be considered, if indicated.

Can CPT 58340 along with 58345 be coded for the above case? Thank you for your time.:)
 

ajmtucker

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only 58345 can be reported - the the other code is used for diagnosic procedures. 58345 includes everything in 58340.
 
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