Ob-Gyn Coding Alert

Question: The ob-gyn performed a hysteroscopy, dilation and curettage (D&C), and rectoscope with partial removal of a fibroid. How should I code this?

New York Subscriber

Answer: Although you may be tempted to report 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C), there are better options.
 
For example, you could bill 58561 (... with removal of leiomyomata). Or, depending on the amount of the fibroid the physician removed, you could choose 58561-52 (Reduced services) if the ob-gyn performed significantly less work than that described in 58561. And, you could use 58558-22 (Unusual procedural services), allowing the modifier to represent the extra work involved for the fibroid.
 
Further, the National Correct Coding Initiative does not bundle 58558 into 58561, so you could report 58561-52 and 58558-51 (Multiple procedures) if the surgeon's documentation supports using the modifiers.