Ob-Gyn Coding Alert

Question: The doctor performed a 58565 but was only able to complete the procedure on one side. And the following week, she performed the same procedure on the other side. The first procedure couldn’t be completed because device was bent upon entry, according to notes. Should I bill 58565at the normal rate for each procedure/DOS?

Wisconsin Subscriber

Answer: No. When the ob-gyn only performs one side at the surgical session, you report 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants) with a modifier 52 (Reduced services). This is a CPT^® instruction. 

Best bet: You will have to communicate to the payer somehowthis was two different procedures. You might think about using modifier RT (Right side) and modifier LT (Left side) as well as modifier 52 for each billing to make the case clearer.

Watch out: You would not use a modifier 76 (Repeat procedure or service by the same physician or other qualified healthcare professional),because it was not repeated on the same side