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aborted procedure

Lynn Posted Tue 16th of February, 2016 07:49:12 AM

HYSTEROSCOPIC FINDINGS: There were 2 tracts, one at 12 o'clock, at the superior edge of the cervix and then what appears to be a false tract extending posteriorly. The hysteroscope did not pass into either tract or into the abdominal cavity, it could not pass into the anterior tract, so given the assumption that 2 tracts were created and one of them most likely to be incorrect, the procedure was aborted.

PROCEDURE IN DETAIL: The correct patient was identified and brought to the operating room with IV fluids running. A timeout was performed. She assisted in transfer from the stretcher to the OR table. SCD placed and started. Monitored anesthesia care was accomplished. A robust time out done. She was placed in the Yellofin stirrups with careful attention to positioning. She was prepped and draped in the usual sterile fashion. An exam revealed the above findings. A single-sided speculum was placed in the vagina Six point paracervical block with 11 cc of 1% lidocaine plain was placed. The anterior lip of the cervix was grasped with a single-tooth tenaculum. Using Pratt and Hegars, the cervix was gently and slowly dilated. An opening was felt to be created, and the uterine sound measured to 8; however, given the difficulty in the dilatation, the hysteroscope was introduced, and the appearance of the 2 tracts strongly suggested that a false tract had been created and so the procedure was aborted. The single-tooth tenaculum was removed. The vagina was cleaned. The speculum was removed. She was undraped and cleaned. She was then taken out of the Yellofin stirrups. She was awoken from anesthesia and transferred from the OR table to the stretcher. She was taken to the recovery room in stable condition. Would you code 58558 modifier 53 ?

SuperCoder Answered Wed 17th of February, 2016 03:17:04 AM

AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.

Lynn Posted Wed 17th of February, 2016 06:49:06 AM

Our drs. performed creation of false tract, and procedure aborted.

Cervical dilatation, diagnostic hysteroscopy
Would you code 58555 modifier 53?

SuperCoder Answered Thu 18th of February, 2016 03:33:02 AM

Yes, 58555 with mod 53 seems appropriate for this scenario.

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