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Failed ablation w/completed D&C

  1. #1
    Seacoast- Dover New Hampshire
    Default Failed ablation w/completed D&C
    Medical Coding Books
    I wanted to use 58563 53 with 5812058. CCI edits say you can't use. Any advice would be helpful.Thanks...
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  2. #2
    Albany, New York
    Would it possible to provide the procedure report?
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    Seacoast- Dover New Hampshire
    Default Failed Ablation and D&C
    Weighted speculum was placed in the posterior vagina and the anterior lip of cervix was grasped with a single tooth tenaculum. Uterus mid position small and mobile. Cervix dilated to a #6 Hagar dilator. Hysteroscope was inserted through the cervical os and a survey of uterus performed. Both tubal ostia were identified. The uterus certainly seemed short. The cavity seemed rather short in the vertical dimension on the hysteroscopic exam. The endometrium looked proliferative. The hysteroscope was rmvd and the uterus sounded to 5 1/2 cm. I was unable to do the NovaSure ablation. In fact, the kit was not opened at all. Gentle curettage was performed and the tissue was sent to pathology. Tenaculum was rmvd, site was dry.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  4. Default hysteroscopy
    It sounds like the doctor reported all parts to qualify for the 58558 which includes hysteroscopy,surgical with sampling(biopsy) of endometrium and or polypectomy with or without D&C you would not report 58563 because the novasure was not used and you would not use 58120 because it is included in 58558

    Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure.

    Dilation of the cervix and curettage of the uterine lining, as described by procedure 58120, is a component of the hysteroscopic biopsy procedure, as represented by procedure 58558. The tissue obtained from the uterine curettage would be submitted for pathologic examination, which constitutes a biopsy of the endometrial cavity

    Therefore, procedure 58120 is not recommended for separate reimbursement when submitted with procedure 58558.

    Last edited by awcoder; 02-04-2009 at 11:35 AM. Reason: mistake

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