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Wiki hysteroscopy with EMB

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tag60

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I've never coded one of these before and want to make sure I came up with correct coding. Note as follows:

Pt here for hysteroscopy and EMB. Has history of endometrial hyperplasia without atypia in 2012 with resolution with placement of IUD. EMB negative in 2013 and 2015.

(Note describes hysteroscopy followed by EMB procedure. Let me know if you need to see this.)

Assessment/Plan: Pt with history of endometrial hyperplasia.
1. Hysteroscopy with limited visualization. No polyps or other masses visualized.
2. Return with Dr. Y for results and management.

Is this 58558, Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C ??

OR

58555, diagnostic hysteroscopy, plus 58100, EMB.

The word "surgical" in first code is throwing me; I'm not sure what that means or how it's different from a diagnostic hysteroscopy.

Please advise accurate coding for this scenario, and -- as always -- I am so appreciative of the help I get on this board!
 
I would say that 58558 covers the whole thing. You would not code the EMB separately. Diagnostic is just "looking", surgical is when they bx, remove polyps or do a d&c.
 
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