General Surgery Coding Alert

  Question: The ob-gyn performed endometrial ablation on a patient after performing cervical dilation on her four hours earlier in the same day. How should we report this visit, and are we allowed to report the dilation separately? Michigan Subscriber Answer: The ablation code depends on the method the physician used, but the dilation can be reported regardless of that method. If the ob-gyn used a hysteroscope to accomplish the ablation, you should: report 58563 (Hysteroscopy, surgical; with endometrial ablation [e.g., endometrial resection, electrosurgical ablation, thermoablation]) for the ablation.
attach modifier -59 (Distinct procedural service) to 59200 (Insertion of cervical dilator [e.g., laminaria, prostaglandin] [separate procedure]). The modifier tells the carrier that the dilation is a distinctly different procedure than the ablation. If the ob-gyn used the thermal balloon procedure to accomplish the ablation, you should: report 58353 (Endometrial ablation, thermal, without hysteroscopic guidance) for the ablation.
attach modifier -59 to 59200. Remember: If the ob-gyn performed the dilation at the same time as the ablation, you cannot report the dilation separately. But some physicians -- such as the one in this example -- may dilate the patient earlier in the day, then perform the ablation later. -- Reader Question and You be the Expert were reviewed by Catherine Brink, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J.