Ob-Gyn Coding Alert

Question: During a hysteroscopy, the ob-gyn distended a patient's uterus. As the physician removed the scope, he noted a perforation in the lower uterine segment at the site of the patient's previous C-section. He did a repair through laparoscopy. Should I code 58555-53 and 58578?

Maryland Subscriber

Answer: First of all, you cannot use modifier 53 (Discontinued procedure), because the ob-gyn did another procedure at the same session. A diagnostic hysteroscopy means diagnostic, and if the ob-gyn completed that part, you should report 58555 (Hysteroscopy, diagnostic [separate procedure]). If an ob-gyn planned another procedure and that failed, then you would use that hysteroscopic code with modifier 52 (Reduced services).

Secondly, you should code the next procedure diagnostically with 998.2 (Accidental puncture or laceration during a procedure). Code 58578 (Unlisted laparoscopy procedure, uterus) suffices because the ob-gyn did a  repair via the scope, not just a diagnostic laparoscopy.