Wiki Transvaginal US after Hysterectomy

[bkhughes]

Patient is status post hysterectomy and is having a transvaginal US for pelvic pain. Since there is no uterus would you add a 52 modifier, the physician did state in the findings that she was s/p hysterectomy, so there was a reason the uterus was not seen or evaluated. According to ACR 2022 US Coding User's Guide if evaluation of the uterus is not documeneted, modifier 52 should be applied.

 

[trarut]

I would use a 52 modifier. The lay description in Codify is "The provider performs a transvaginal ultrasound to assess the reproductive organs, that is, the uterus, fallopian tubes, ovaries, cervix, and vagina in a female patient." The uterus isn't present to be imaged so I consider that a reduced service. I also consider ACR an authoritative resource for coding advice. When I worked with gyn oncologists, the SGO was our authoritative source if we needed coding advice.