Question: The ob-gyn performed a hysteroscopy with dilation and curettage (D&C) and then removed a 4-cm cervical polyp without the help of a hysteroscope. How should I code the cervical polyp removal? 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.
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Answer: You can cover the entire procedure under one code: 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C).
The fact that the ob-gyn removed the hysteroscope before removing the polyp doesn't matter because the entire procedure occurred during the same surgical session.