Ob-Gyn Coding Alert

Question: One of my ob-gyns attempted a hysteroscopy with dilation and curettage (D&C) but could not identify the cervix. Should I bill 58558 with modifier 53? Then the op report reads, -Reprepped the abdomen and used an 18 gauge spinal needle to break through the abdominal wall into the endometrial cavity and aspirated approximately 250 cc of purulent material.- What code should I use for this procedure?


Florida Subscriber

Answer: First, you should not add modifier 53 (Discontinued procedure), because the ob-gyn performed another procedure during the same session. In other words, modifier 53 means that all surgery stops. So you should bill 58558-52 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C; reduced service), with modifier 52 representing the failed procedure.

The closest code for the drainage would be 49021 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous). Unfortunately, this code is for drainage of an abdominal abscess, and your ob-gyn went into the uterus (for which there is no code). So you should bill this with 58999 (Unlisted procedure, female genital system [nonobstetrical]) and then let the payer know it was similar to 49021.

The answers for Reader Questions and You Be the Coder were provided  by Melanie Witt, RN, CPC-OGS, MA, an ob-gyn coding expert based in Guadalupita, N.M.