Ob-Gyn Coding Alert
Wait for the Final Path Report Before Coding Resection
Question: The patient had miscarried about two weeks prior, but also had a pregnancy a prior pregnancy loss six months prior. When she continued to bleed, the ob-gyn performed an endometrial biopsy. The path report showed placental site nodule and proliferative endometrium. So he took her to the operating room and took a look with the hysteroscope. He saw the thickened site and resected it with the Myosure. He made no mention of a fibroid prior to the procedure. How should I report this?
Texas Subscriber
Answer: You need to wait for the final path report that tells you what he actually resected. You may end up only getting to bill 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) if he didn’t find any fibroid, but your diagnosis will only be bleeding in that case. You may be reporting 626.8 (Other disorders of menstruation and other abnormal bleeding from female genital tract) if you have no evidence of a fibroid or a polyp, since the nodule found during the biopsy did not confirm products of conception.
ICD-10: When your diagnosis system changes to ICD-10, code 626.8 will become N93.8 (Other specified abnormal uterine and vaginal bleeding).
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