Ob-Gyn Coding Alert

Question: My ob-gyn performed an endometrial polypectomy in the office. He did not use the hysteroscope. The patient had an endometrial biopsy, and the ob-gyn removed a polyp. Do I only code the endometrial biopsy?

Wyoming Subscriber

Answer: You would report a polyp removal with 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]), but the Correct Coding Initiative (CCI) bundles it into 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]). Therefore, you can only report 58100.

Modifier possibility: You might consider adding a modifier 22 (Increased procedural service) if your ob-gyn's documentation supports significant additional work in removing the polyp.