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58563 & 58120 ??????

  1. #1
    Exclamation 58563 & 58120 ??????
    Medical Coding Books
    I found an older post about these two codes billing together from March which states the D&C is needed to scrape the problem tissue away before doing the ablation or the ablation will not work.

    One of our offices wants to bill them together, the hospital did not bill both, just the 58563, per the OP Note the D & C (58120) was done first, then the Endometrial Ablation (58563) was completed after (same session).

    Per CCI Edits they should not be billed together, but if documentation supports, modifier is allowed.

    When should a modifer be used when both procedures are done?

    If the statement is true that a D&C has to be done in conjunction with the ablation, wouldn't it then be included in the code description, and under the CCI Edit rule no modifier be allowed?

    So very confused with this situation , new to OB billing and want to be sure this gets coded correctly.

    Any info would be great! Thanks so much!

  2. Unhappy 58563 and 58120
    Dear Volleyb13, I've tried coding both and haven't found a payer (or an outside coding auditor, for that matter) who will allow it, even though CCI allows it with a modifier. I've appealed denials but it always comes back as 'unbundling.' I feel like this is something CPT (or whoever) should review. The D+C uses different instrumentation, the surgeon has to apply separate clinical judgement, the D+C uses more time, and the OR has to allocate more resources. All of this SHOULD point to allowing another code with a modifier - but it never works. The D+C is considered part of the code for the hysteroscopy with ablation.

  3. #3
    I have been billing them seperate with modifier 51 on the D&C on all insurances except MCR - just to see who would pay it and who wouldn't. I found that Anthem is paying these two codes when billed together with the mod 51.....but Anthem FEP does not. The only other insurances I've tried so far are UHC and CIGNA -- and they both consider the D&C global to the Ablation. So --- if the patient has any form of Anthem (except FEP) we are billing the two codes together with mod 51 ---- otherwise, we only bill the 58563.

    Hope this was helpful.

  4. #4
    OK, here's my 2 cents... A 58558 is a surgical hysteroscopy "with or without D&C" & is worth 9.13 RVUs (at least for my geographical area, it is). The 58563 is a surgical hysteroscopy with endometrial ablation and is worth 9.37 RVUs (when performed at a non-office setting). It makes sense to me that if the 58558 includes D&C, then so would the 58563. That could be flawed logic, but that's all I've got...

    Becky "Two Cents" Hardin, CPC

  5. Default Global
    Does CPT 58563 have a global period?

  6. Default ma cpc
    58563 no FUD

    In our practice, our Doctors do an Endometrial biopsy in the office first before scheduling the Endometrial Ablation. In our Area UHC requires this as a "prerequisite". So basically in lieu of the D&C the EMB is performed and paid by the ins carrier. This way we have a status on the endometrium before the ablation is performed.

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