shakishat
New
The provider wants to bill 57455 & 58100 with modifier 53, I don't think we can bill Endometrial Sampling since there was a successful Colposcopy. I could not find anything on this. Any help is appreciated. Thanks
Procedure Documentation
Colposcopy Procedure Note (UEHRC):
Risks, benefits, indications and alternatives for the procedure were reviewed with the patient. All questions were answered. Informed consent was obtained. Post-care instructions were given to the patient.
INDICATION: neg pap with HR HPV positive 16
A speculum was placed into the vagina. The cervix and upper vagina was painted with Acetic Acid solution. The entire transformation zone was not visualized. Lugol's solution was applied.
Colposcopy revealed the following:
Colposcopic exam: Unsatisfactory
Pap was not repeated.
GROSS OBSERVATIONS: no acetowhite changes
7:00 negative Lugol's uptake barely and very minimal
soft bx and exx used
Biopsies performed: 7:00
ECC was attempted but cervix stenotic. no bleeding noted
Colposcopic Impressions: Normal
The patient tolerated the procedure well. She was monitored per protocol and discharged home after meeting criteria.
Endometrial Biopsy Procedure Note (UEHRC):
Risks, benefits, indications and alternatives for the procedure were reviewed with the patient. All questions were answered. Informed consent was obtained. Post-care instructions were given to the patient.
With the patient in the dorsal lithotomy position, the speculum was placed into the vagina. The cervix was prepped with Betadine. The anterior lip of the cervix was grasped with a tenaculum. An endometrial sampling device was unable to be inserted past 2 cm. tried dilator with no success. procedure was discontinued.
Procedure Documentation
Colposcopy Procedure Note (UEHRC):
Risks, benefits, indications and alternatives for the procedure were reviewed with the patient. All questions were answered. Informed consent was obtained. Post-care instructions were given to the patient.
INDICATION: neg pap with HR HPV positive 16
A speculum was placed into the vagina. The cervix and upper vagina was painted with Acetic Acid solution. The entire transformation zone was not visualized. Lugol's solution was applied.
Colposcopy revealed the following:
Colposcopic exam: Unsatisfactory
Pap was not repeated.
GROSS OBSERVATIONS: no acetowhite changes
7:00 negative Lugol's uptake barely and very minimal
soft bx and exx used
Biopsies performed: 7:00
ECC was attempted but cervix stenotic. no bleeding noted
Colposcopic Impressions: Normal
The patient tolerated the procedure well. She was monitored per protocol and discharged home after meeting criteria.
Endometrial Biopsy Procedure Note (UEHRC):
Risks, benefits, indications and alternatives for the procedure were reviewed with the patient. All questions were answered. Informed consent was obtained. Post-care instructions were given to the patient.
With the patient in the dorsal lithotomy position, the speculum was placed into the vagina. The cervix was prepped with Betadine. The anterior lip of the cervix was grasped with a tenaculum. An endometrial sampling device was unable to be inserted past 2 cm. tried dilator with no success. procedure was discontinued.
