Sandra Posted Tue 26th of January, 2016 18:14:43 PM
I have asked this question before and keep getting directed to use a hysteroscopy(58563) code versus a laparoscopy code for Operative Laparoscopy ABLATION of ENDOMETRIOSIS and Chromotubation? Plus we did a HYSTEROSCOPY for BOTH Endometrial Polypectomy AND Resection of endometrial Synechiae?
Operative report reads: A 33-year old gravida 0, preparing to undergo infertility therapy, noted with a Hysterosalpingogram suspicious for endometrial synechiae and polyp as well as possible left hydrosalpinx. Her history was significant for progressive pelvic pain suggestive endometriosis, now for surgical evaluation.
OPERATIVE FINDINGS: Examination under anesthesia revealed uterus, which was of normal size, shape, contour, anteverted, and mobile. There were no palpable adnexal masses. Uterus sounded to 8.5 cm. LAPAROSCOPY revealed 3 to 4 cul-de-sac and ovarian fossa powder-burn lesions, bilateral grossly normal ovaries and fallopian tubes as well as appendix and the liver edge. Both fallopian tubes were noted to freely spill at chromotubation. HYSTEROSCOPY revealed five to seven endometrial polyps diffusely, the largest was 3 cm long, the smallest was 1 cm. As well, they were two to three thin filmy synechiae, all were resected in a serial fashion and at the conclusion of the procedure, there was a normal global cavity and bilateral Ostia noted and cleared for fertility therapy.
Diagnosis listed: Endometrial polyps; Endometrial synechiae; Stage II endometriosis; Bilateral normal/patent fallopian tubes.
How would I bill this to insurance?
SuperCoder Answered Wed 27th of January, 2016 00:02:25 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.