Wiki Repeat EMB that was initially performed at another location.

[kheslin87]

Good afternoon,

I code for a FQHC and one of the GYN providers on 07-21-2023 performed a second attempt EMB for postmenopausal bleeding and endometrial thickening. The EMB was initially performed at a hospital per patient's EHR.
Documentation states:
"She recently had an EMB tried on 6/28/23 but path showed rare and fragments of cells, "less than optimal evaluation of endometrial pathology" and presents for a second attempt today.
No LMP recorded. Patient is perimenopausal."

The codes dropped are N95.0 for postmenopausal bleeding and R93.89 for endometrial thickening for 58100. Since this is the second attempt, is there a more appropriate code or modifier to help describe this being a second attempt? I know when patients come in for a repeat pap due to the sample being unsatisfactory, we use one of the codes from R87. However, a fellow coworker and I have not encountered this scenario before.

Any advice or experience is greatly appreciated.

Thanks in advance!

 

[csperoni]

If the original procedure was done by another provider in another location 4 weeks earlier, I do not see a need for a repeat modifier.
I am not aware of any unsatisfactory endometrial biopsy diagnosis like there is for PAP.
I would code this as you have indicated - 58100 for EMB with N95.0 & R93.89.