Uterine Septum question for CPT

dmarshall

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Hello OBGYN Group,

Doctor notes in the hysteroscope procedure that it appeared to be a uterine septum was reduced with subsequent dilator. My question is does this qualify for using 58560? When I sent an inquiry to the doctor she states, no, it literally came down when we finally got around it with the dilators, it actually tore off. I know I can bill the 58662 & 58558 codes for this surgery, would appreciate some coding advice on the septum portion. Please see op report below:

A 5mm trocar was then advanced under direct visualization of the laparoscope. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. A suprapubic incision was then made under direct visualization of the laparoscope after skin was infiltrated as above with marcaine and incised using a scalpel.5 mm port also placed with the same technique . A 5mm left lateral port was placed 2cm superior and medial to the ASIS with same technique. Patient was then placed in trendelenburg position. The above findings were noted. The uterus was elevated from the pelvis with sponge stick. Both ovaries and tubes visualized. Laparoscopy scissors were utilized to reduce adhesions of left ovary to left side wall and bowel. It was carefully reduced and increased mobility of the ovary was noted after. Next, a survey of the pelvis revealed small, white/lacy lesions, which were done by fulguration. The abdomen was then copiously irrigated with normal saline and all sites noted to be hemostatic. Following the procedure all instruments were removed from the abdomen. Pneumoperitoneum was released, attention was now turned to vaginal part of surgery. The anterior lip of cervix was grasped with a single tooth tenaculum and sounded to 6cm. The cervix was sequentially dilated to accommodate the 5-mm hysteroscope. A 5-mm 0-degree hysteroscope was introduced under direct visualization, and the uterus was distended with normal saline. Right cornua was identified and what appeared to be a uterine septum was reduced with subsequent dilator. At this time, left cornua was identified. The hysteroscope was then withdrawn and sharp curettage was performed, which revealed a good uterine cry or gritty feeling was noted on all sides of the uterus. Endometrial curettings were collected and sent to pathology. After the procedure, all instruments were removed from vagina. The cervix was noted to be hemostatic. The patient tolerated the procedure well. All counts were correct times two. The patient was taken from the operating room in stable condition.


Thank you all so much for your assistance!
 

csperoni

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"58560 In this procedure, the provider removes an intrauterine septum, or a band of tissue that separates the uterine cavity into two sections, to restore the uterus to a single cavity. The provider uses a hysteroscope to perform this procedure."
My opinion is that the 58560 is billable. The codes are not CCI edits. The provider actually did remove the uterine septum, albeit more easily than usual.
If you feel uncomfortable using 58560 (I would not), you could consider using -52 for reduced procedure.
 

dmarshall

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"58560 In this procedure, the provider removes an intrauterine septum, or a band of tissue that separates the uterine cavity into two sections, to restore the uterus to a single cavity. The provider uses a hysteroscope to perform this procedure."
My opinion is that the 58560 is billable. The codes are not CCI edits. The provider actually did remove the uterine septum, albeit more easily than usual.
If you feel uncomfortable using 58560 (I would not), you could consider using -52 for reduced procedure.

Thank you so much for your confirmation of coding, I appreciate it, I feel confident in billing the 58560 code as well.
 

Cmama12

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Hi, I have a different take on this. - the lay description for 58560 states The provider identifies the septum and resects it using scissors, a wire loop electrode, or laser. As even the provider states, it tore off on entry with the dilators, so I personally would not code this.

The provider also states appeared to be a uterine septum - unless they definitively state it elsewhere, then it is uncertain as well.
 

csperoni

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I definitely missed the "appeared" portion. I personally think this may have been just a poor choice of words by the clinician. This is certainly one of those grey areas. To me, with grey areas, as long as you can support your coding choices, there is not necessarily a right or a wrong answer. I do see Meg's perspective, but since there was an instrument used (although not one listed in the lay term), I still feel 58560 is warranted.
I might ask the provider if she wants to amend the record to clarify anything.
 

dmarshall

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Thank you for your input Meg and Christine, I will request clarification from the provider as back up for justification, I totally agree. Thank you again!
 
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