Ob-Gyn Coding Alert

Question: We recently started doing diagnostic hysteroscopy in our ob-gyn office. (The hysteroscope is only for a diagnostic hysteroscopy). We have written information from the hysteroscope company that says, “If a diagnostic hysteroscopy (58555) is performed followed by a procedure such as sampling (biopsy) of endometrium and/or polypectomy, with/without D&C, without a scope, you can code two procedures. According to the CPT^® Assistant (2003), code 58558 may be reported when a procedure is performed without a scope following a diagnostic hysteroscopy.” Is this information still correct? My understanding is that 58558 is a surgical procedure, which can only be done through the hysteroscope. Is this correct?

New York Subscriber

Answer: Per CPT^®, if a hysteroscope is used at any time during the session at which a surgical procedure is performed inside the uterus and that procedure has a code that describes it, you bill the hysteroscopic procedure code (e.g., did diagnostic hysteroscopy, removed scope, then ablated the endometrial lining). This would be 58563 (Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation), not 58555 (Hysteroscopy, diagnostic [separate procedure]) plus 58353 (Endometrial ablation, thermal, without hysteroscopic guidance).

However, remember that there is no code for excision of a uterine polyp except with use of a hysteroscope.

Also keep in mind that not every hysteroscopic procedure is allowed to be performed in the office setting. Codes 58559 (Hysteroscopy, surgical; with lysis of intrauterine adhesions [any method]), 58560 (Hysteroscopy, surgical; with division or resection of intrauterine septum [any method]) and 58561 (Hysteroscopy, surgical; with removal of leiomyomata) must be performed in a facility setting. Code 58555 is also a “surgical” procedure, and it is the site of service allowed for each code that determines where it can be performed.