# evacuation of hematometra



## huntersmum (Oct 31, 2011)

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)?


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## ajs (Oct 31, 2011)

huntersmum said:


> 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.


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## huntersmum (Oct 31, 2011)

Thank you!


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## tcowboys07 (Oct 31, 2011)

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.


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## ajs (Nov 1, 2011)

tcowboys07 said:


> 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.


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