# gyn exam under anethesia/dilation & biopsy



## cynannthomas (Aug 31, 2009)

Anyone know how to code a gyn exam under anethesia w/dilation & endometrial  biopsy?  Thanks!


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## FTessaBartels (Aug 31, 2009)

*58558*

NOT my area of expertise ... but would 58558 work?

F Tessa Bartels, CPC, CEMC


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## imjsanderson (Aug 31, 2009)

CPT 57410 for the pelvic exam under anesthesia
CPT 58100 for the biopsy, although 58100 is bundled into 57410
Bill the code with the highest RVU value for the most $$


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## FTessaBartels (Sep 1, 2009)

*58100 withOUT dilation*

58100 is WITHOUT dilation ... so I'm not sure that's correct. 

57410 would be bundled with 58558, so if the documentation supports 58558 you would not separately code for 57410.

F Tessa Bartels, CPC, CEMC


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## imjsanderson (Sep 2, 2009)

Let me re-phrase this:  57410 is an integral portion of the surgical procedure, therefore you would code 58100 for the biopsy which would also include 57410.  CPT 58120 is a non-ob dilation and currettage but is also bundled with 58100.  

CPT 58558 is hysteroscopy, if this is a hysteroscopic procedure, than by all means, 58558 is the correct code.  The original question did not mention hysteroscopy.


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