Ob-Gyn Coding Alert

Question: My ob-gyn documented the following note:

Procedures: Administered injection. Patient given one dose of Atropine. Site - Left Upper Quadrant Lot # 0211317 Expiration: 2/2013 Patient given 60mg of Tordol. Site - Left Upper Quadrant Lot@ DK 12011 Expiration: 11/2012. Thermachoice Ablation: Betadine was used to cleanse vaginal vault and cervix. Superficial anterior cervix was injected with 2cc 0.05% Carbocaine (20cc mixed with 20cc Saline=40cc total volume) using a 10cc control syringe with a 22 gauge needle and a needle extender. Anterior cervix was grasped with a single toothed tenaculum. 5cc Carbocaine was injected at 4, 8, 10 and 2 o'clock just medial to the cervico-vaginal reflection. Waited (5) minutes to ensure a complete paracervical block. Cervix was dilated with the Pratt dilators. The 5mm hysteroscope slid into the cervix with ease. General survey revealed normal endometrial cavity. Endometrial biopsy was performed to ensure adequate anesthesia. Two passes were performed and adequate tissue was obtained. The Thermachoice balloon was primed, then prepped and inserted into the uterus. This passed to 10cm. The ablation was then performed per the manufacturer's instructions and without complication. The tenaculum was removed and hemostasis observed. The patient tolerated the procedure well.

How should I report this? Is this truly just an ablation?

Maine Subscriber

Answer: Yes. You should report 58563 (Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation) because the ob-gyn used a hysteroscope. Although he also indicated he did an endometrial sampling prior to inserting the ablation device, you should always consider that procedure, when performed, as bundled. The reason is that you may not code for removing part of the endometrial lining by more than one method.