ICD 10 Coding Alert
Wait for the Final Path Report Before Coding Resection
Question: The patient had miscarried about two weeks prior, but also had a pregnancy a prior pregnancy loss six months prior. When she continued to bleed, the ob-gyn performed an endometrial biopsy. The path report showed placental site nodule and proliferative endometrium. So he took her to the operating room and took a look with the hysteroscope. He saw the thickened site and resected it with the Myosure. He made no mention of a fibroid prior to the procedure. How should I report this?
Texas Subscriber
Answer: You need to wait for the final path report that tells you what he actually resected. You may end up only getting to bill 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) if he didn’t find any fibroid, but your diagnosis will only be bleeding in that case.
You may be reporting current ICD-9 code 626.8 (Other disorders of menstruation and other abnormal bleeding from female genital tract) if you have no evidence of a fibroid or a polyp, since the nodule found during the biopsy did not confirm products of conception. However, when your diagnosis system changes to ICD-10, code 626.8 will become N93.8 (Other specified abnormal uterine and vaginal bleeding).
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Wait for the Final Path Report Before Coding Resection
Question: The patient had miscarried about two weeks prior, but also had a pregnancy a prior [...]
