Hello OB/GYN Group,
We have a patient that was scheduled for a Colposcopy the colpo was unable to completed:
Unable to successfully perform colposcopy due to patient discomfort. Multiple attempts with speculum were performed to visualize cervix but limited views of the posterior aspect of cervix. Two right angle retractors were then used visualizing the posterior cervical lip more optimally and an Allis clamp was used to apply traction and bring cervix forward without success- presume limited mobility of uterus due to fibroids. Due to patient discomfort and request, procedure abandoned. Would advise for performing colposcopy at time of hysteroscopy D&C.
Colposcopy
Date/Time: 1/4/2024 3:46 PM
Performed by: Dr X
Authorized by: Dr X
Procedure location: cervix
Consent:
Patient questions answered: yes
Risks and benefits of the procedure and its alternatives discussed: yes
Procedural risks discussed: Bleeding, infection and possible continued pain
Consent obtained: Written and verbal
Consent given by: Patient
Indication:
Cervical indication(s): high-risk HPV positive and cervical LSIL
Pre-procedure:
Premeds: Acetaminophen
Speculum was placed in the vagina: yes
Comments:
UNABLE TO COMPETE PROCEDURE
Unable to visualize cervix 2/2 significantly retroverted cervix that was very anterior. Attempted to visualize with speculum. Two right angle retractors were inserted to attempt to achieve visualization, the posterior lip of the cervix was see and grasped with Allis clamp however unable to visualized anterior aspect or cervical os. Given patient discomfort and difficulty of visualization.
Recommend colposcopy to be done with planned hysteroscope.
Medicare has rejected the claim as inappropriate modifiers:
57452-52,GC
Should this be billed any other way? Thank you for input, greatly appreciated.
Dorine Marshall,CPC, COBGC
We have a patient that was scheduled for a Colposcopy the colpo was unable to completed:
Unable to successfully perform colposcopy due to patient discomfort. Multiple attempts with speculum were performed to visualize cervix but limited views of the posterior aspect of cervix. Two right angle retractors were then used visualizing the posterior cervical lip more optimally and an Allis clamp was used to apply traction and bring cervix forward without success- presume limited mobility of uterus due to fibroids. Due to patient discomfort and request, procedure abandoned. Would advise for performing colposcopy at time of hysteroscopy D&C.
Colposcopy
Date/Time: 1/4/2024 3:46 PM
Performed by: Dr X
Authorized by: Dr X
Procedure location: cervix
Consent:
Patient questions answered: yes
Risks and benefits of the procedure and its alternatives discussed: yes
Procedural risks discussed: Bleeding, infection and possible continued pain
Consent obtained: Written and verbal
Consent given by: Patient
Indication:
Cervical indication(s): high-risk HPV positive and cervical LSIL
Pre-procedure:
Premeds: Acetaminophen
Speculum was placed in the vagina: yes
Comments:
UNABLE TO COMPETE PROCEDURE
Unable to visualize cervix 2/2 significantly retroverted cervix that was very anterior. Attempted to visualize with speculum. Two right angle retractors were inserted to attempt to achieve visualization, the posterior lip of the cervix was see and grasped with Allis clamp however unable to visualized anterior aspect or cervical os. Given patient discomfort and difficulty of visualization.
Recommend colposcopy to be done with planned hysteroscope.
Medicare has rejected the claim as inappropriate modifiers:
57452-52,GC
Should this be billed any other way? Thank you for input, greatly appreciated.
Dorine Marshall,CPC, COBGC