Ob-Gyn Coding Alert

Question: My ob-gyn removed polyps and fibroids via a hysteroscope. The path diagnosis is fibroid. What is the difference between using 58561 and 58558? Are they the same procedure and the only difference is that I should use one for the polypectomy and the other for the removal of fibroids? And if so, why does 58561 have more RVUs?

Rhode Island Subscriber

Answer: If your ob-gyn removed both polyps and fibroids, bill only for the more extensive procedure, which is 58561 (Hysteroscopy, surgical; with removal of leiomyomata) -- unless she also performed a dilation and curettage.

If she did, you can bill both 58561 and 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C).

Polyps are small growths on the surface of the uterine wall that are easy to remove. Fibroids are larger and usually imbedded in the uterine wall and require more work to remove, hence you get paid more when your ob-gyn removes fibroids.