Misty Posted Wed 24th of January, 2018 17:16:12 PM
Op note: A weighted speculum was placed into the vagina and surprisingly the endocervical os was dilated and I could see the endocervical mass and extracted this in its entirety. I then performed a fractional D&C ad did an endocervical curettage next. Then, I sounded the uterus and dilated the endocervical canal with Hegar dilators to accept the MyoSure hysteroscope. Inside the uterine cavity, everything appeared normal. The hysteroscope was removed, and then a sharp curettage was performed until a uterine cry was heard.
Can you tell me what the proper CPT codes I would bill. Thanks
SuperCoder Answered Thu 25th of January, 2018 02:24:08 AM
Greetings from SuperCoder!
As per provided documentation, we can say that “when the provider places a hysteroscope during the surgical procedure, even if the actual D&C is performed without using the hysteroscope, report the more extensive procedure code 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C).”
If your documentation says something different, we would like you to send more information from the medical record.
Please feel free to write if you have any question.