Wiki hysteroscopy dilation with ablation aborted

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TanBro

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I just want to confirm I'm thinking of the correct CPT code. Doc did a Bilateral salpingectomy (58661) with a Hysteroscopy dilation and endometrial ablation (58563). My question is when proceeding to do the ablation it was unsuccessful and it was aborted, should I still code 58563 with modifier 52? It was a aborted due to attempting to place the endometrial ablation device was unsuccessful and when they tried again they noticed a small tear in the cervical canal.

Thanks in advance.
 
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Hello, I am a new coder and still learning but here are my thoughts. I will code Hysteroscopic procedure with modifier 53. Modifier 53 is for incomplete procedure when there was a medical obstruction that prevented to complete the procedure intended. 52 modifier is when MD does it intentionally - incomplete procedure.
 
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natashalage said:
Hello, I am a new coder and still learning but here are my thoughts. I will code Hysteroscopic procedure with modifier 53. Modifier 53 is for incomplete procedure when there was a medical obstruction that prevented to complete the procedure intended. 52 modifier is when MD does it intentionally - incomplete procedure.
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Even though they did the Hysteroscopic D&C and just aborted the ablation?
 
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Hi Tanya, if there was a completed procedure, then you would code that. So 58558 for the hyst d&c and 58661.
 
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tanyabrown said:
But they attempted the ablation twice, do they not get any reimbursement for that?
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You could possibly add a modifier -22 to 58558 if the extra work was significant and well documented. Otherwise, some are easy, some are hard. I would not report 58563 as this procedure was not performed.
 
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