Results 1 to 5 of 5

evacuation of hematometra

  1. #1
    Exclamation evacuation of hematometra
    Medical Coding Books
    Help! One of my docs did an evacuation of hematometra. Description: The pipelle was attached to a 10cc syringe and 18cc of bloody fluid was aspirated from the cervix. The uterus was retroverted and sounded to 7cm's . After 18cc of bloody fluid was aspirated, a vigorous four quadrant biopsy was performed, removing a minimal amount of tissue. this bloody fluid and tissue was placed in formalin and sent to pathology.

    I can't find anything that fits.......any help would be appreciated. Do I even have anything above the biopsy (58100)?

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by huntersmum View Post
    Help! One of my docs did an evacuation of hematometra. Description: The pipelle was attached to a 10cc syringe and 18cc of bloody fluid was aspirated from the cervix. The uterus was retroverted and sounded to 7cm's . After 18cc of bloody fluid was aspirated, a vigorous four quadrant biopsy was performed, removing a minimal amount of tissue. this bloody fluid and tissue was placed in formalin and sent to pathology.

    I can't find anything that fits.......any help would be appreciated. Do I even have anything above the biopsy (58100)?
    It sounds like 58100 with some additional work, so your best bet may be to code the 58100 with modifier 22 and submit the notes for additional reimbursement.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Default
    Thank you!

  4. #4
    Default
    I think you should query the physician to find out if this is even significant enough to code as a separate procedure. 18cc of fluid is not a very significant amount. If however, the MD has documented that this is significant then it would full under 58120 "diagnositic/theraputic aspiration of the uterus" but again, I would query the md.

  5. #5
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by tcowboys07 View Post
    I think you should query the physician to find out if this is even significant enough to code as a separate procedure. 18cc of fluid is not a very significant amount. If however, the MD has documented that this is significant then it would full under 58120 "diagnositic/theraputic aspiration of the uterus" but again, I would query the md.
    It does not meet the criteria for 58120 Dilation and curettage as neither of those things were performed. It was an endometrial biopsy with an aspiration before starting the biopsy.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

Similar Threads

  1. Evacuation of abdomen
    By dmclain1974 in forum General Surgery
    Replies: 1
    Last Post: 06-05-2014, 08:17 AM
  2. Hematoma evacuation
    By jperkins in forum Cardiology
    Replies: 1
    Last Post: 03-01-2011, 07:03 AM
  3. Evacuation of hematoma
    By carol52 in forum General Surgery
    Replies: 1
    Last Post: 11-17-2010, 07:41 AM
  4. evacuation of uterus
    By house in forum OB/GYN
    Replies: 3
    Last Post: 02-05-2009, 04:04 PM
  5. Colonic evacuation
    By cynthiar in forum Gastroenterology
    Replies: 5
    Last Post: 03-08-2008, 08:17 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.