Ob-Gyn Coding Alert

Question: The physician performed a fractional D&C and removed three polyps. A hysteroscopy was not done. Should I only code for the D&C, or is there a separate code for the polypectomy?

Indiana Subscriber

Answer: If the polyps were on the uterine lining, you have the option of billing hysteroscopy with D&C, and adding modifier -52 (Reduced services) to 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). Or, you can bill 58120-22 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]; unusual procedural services) if the removal of the polyps represented significant additional work. The second option is probably the more accurate method of coding, because the first option may result in overpayment if the payer does not recognize modifier -52, which can lead to complications in the event of an audit.