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Tammy Posted Thu 05th of November, 2015 15:09:34 PM

Attempted dilatation of cervical canal.
Attempted hysteroscopy.

COMPLICATIONS: Perforation of the cervical canal. Patient went in for tissue sampling.

The hysteroscope was then used to visualize the cervical canal and there was also visualization of bowel indicating that had been perforation of the cervix.

injury occurred during surgery and the inability to obtain tissue sampling has had been recommended.

Please let me know on CPT and modifier. would it be 52 or 53? thanks much!!

SuperCoder Answered Fri 06th of November, 2015 05:24:09 AM

Thanks for the question,

CPT code 58558 is appropriate to code this procedure with modifier 53.

Append modifier 53 to a diagnostic or surgical procedure when the physician begins a procedure and then decides to terminate it, since continuing the procedure will threaten the patient’s health

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