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Local Pain Management

  1. Smile Local Pain Management
    Medical Coding Books
    We perform in office hysteroscopies, Essure, and Ablations. Depending on the procedure, we will administer Toradol 30mg IM. Is it possible to bill separately for the Toradol (J code) or is it considered inclusive?

  2. Default
    The toradol should be oncluded in the procedure, however, AGOC does say you can bill a paracervical block if performed:

    Correct Reporting of Paracervical Block with Hysteroscopy Procedures

    Written by Donna Tyler, CPC, COBGC, ACOG Coding Specialist

    There is a difference between commercial and Medicare payers when reporting a paracervical block (CPT-4 code 64435) separately from the hysteroscopy procedures. The 2009 ACOG Coding Manual differentiates this reporting.

    Non-Medicare Reporting
    For non-Medicare patients, according to the ACOG Coding Manual the following hysteroscopy codes were valued to include the paracervical block:

    58563 (Hysteroscopy, surgical; with endometrial ablation (eg, endometrial
    resection,electrosurgical ablation, thermoablation))

    58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion
    by placement of permanent implants)

    For these two codes only, the paracervical block should not be reported separately.

    However, the Coding Manual states that paracervical block code 64435 may be reported separately when performed with the following hysteroscopy codes:
    58555 (Hysteroscopy, diagnostic (separate procedure))
    58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy,
    with or without D & C)
    58559 (Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method))
    58560 (Hysteroscopy, surgical; with division or resection of intrauterine septum (any
    58561 (Hysteroscopy, surgical; with removal of leiomyomata)
    58562 (Hysteroscopy, surgical; with removal of impacted foreign body)

    Medicare Reporting
    The 2009 ACOG Coding Manual also specifies, that for Medicare patients based on the Correct Coding Initiative (CCI), when reporting hysteroscopy procedures the paracervical block is bundled into codes 58555, 58558, 58559, 58560, 58561, 58562 and 58563. However, Medicare will provide separate reimbursement from the aforementioned hysteroscopy codes when the paracervical block (code 64435) is appropriately performed and submitted with a modifier. To differentiate between the hysteroscopy procedure and paracervical block, modifier 59 (distinct procedural services) should be used (eg, 58558, 64435-59).

    In addition, the Coding Manual indicates that for Medicare patients, CPT-4 code 64435 is not bundled into hysteroscopy code 58565. This is the only hysteroscopy code that Medicare does not bundle the paracervical block into. As such no special modifier is required in order to receive separate reimbursement.

    Coding Resource
    If you haven't purchased a copy of the 2009 OB/GYN Coding Manual: Components of Correct Procedural Coding , here's why you should! The Coding Manual has been extensively revised for 2009, and now includes the bundling information for each code both from Medicare's National Correct Coding Initiative (CCI) and for non-Medicare patients, ACOG's clinical vignettes. This change allows coders to compare the bundling issues between Medicare and non-Medicare patients. The ACOG Coding Committee Opinions that relate to coding and reimbursement issues are included, and all codes are grouped by body system or type of service to complement the AMA CPT book designations. Updated annually by ACOG, this manual contains 2009 CPT codes and descriptions for procedures performed most often by ob-gyns.

    To place your order contact the ACOG distribution center at 1-800-762-2264 or place your credit card order online at:

    Questions and/or comments may be sent to ACOG's Coding Staff via email at

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    Savonne Montue, MBA, RHIT, ACS-OB, COBGC
    Manager, Coding Education

    Donna Tyler, CPC, COBGC
    Coding Specialist

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    Copyright © 2009 American College of Obstetricians and Gynecologists. All rights reserved.

  3. #3
    Kansas City, MO
    I have that ACOG article also, but I would like to add a word of caution. You need to stay on top of your commercial carrier policies. Several of the large commercial insurance companies have within the last year published that they use the NCCI edits in addition to their own code editing software. So, if you carrier has come out and said they use NCCI, it would be incorrect to bill the block in addition to the procedure.

    I know, the good news just abounds at times.
    Angela Jordan, CPC, COBGC, AAPC Fellow
    Senior Managing Consultant
    Medical Revenue Solutions, LLC
    AAPC National Advisory Board - Southwest
    AAPCCA BOD Chair 2012-2013

  4. #4
    We also perform AB, Colpo and LEEP procedures as well as hysteroscopies, Essure, and Ablations in office. Depending on the procedure, we will perform a paracervical uterine nerve block with those procedures. Is it possible to bill separately for the nerve block or is it considered inclusive?

  5. #5
    Kansas City, MO
    It is considered bundled for most of the codes I have checked in the Gyn section of codes. Here is the link to the CMS NCCI database that way you can look up the codes that you specifically use.
    Angela Jordan, CPC, COBGC, AAPC Fellow
    Senior Managing Consultant
    Medical Revenue Solutions, LLC
    AAPC National Advisory Board - Southwest
    AAPCCA BOD Chair 2012-2013

  6. Default
    is this information accurate today, 2010? Things change so fast. I am working on getting access to the articles on ACOG to update.

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