Ob-Gyn Coding Alert

Question: My ob-gyn's documentation states the following: Attempted dilation and curettage Partial excision of cervical fibroid

Complications: Inability to cannulate the cervix Findings: 2 cm wide apparent fibroid filling the endocervical canal

"... The cervix was visualized and there was a firm rounded lesion at the cervical os. Initially, this was felt likely to be a cyst. An attempt was made to dilate the cervix and the endocervical canal could not be identified. I then incised the lesion hoping for drainage of a cervical cyst. However, it turned out to be a solid lesion. This was partially excised sharply in hopes of identifying the endocervical canal. However, I was able to size it at least half way up to the endocervical canal. Still unable to identify the cervical os or passageway for instruments. Then called for lacrimal duct probe. Multiple attempts were made to identify the cervical os or endocervical canal, none of which were successful. The firm lesion totally occluded the lumen of the endocervical canal. It was determined to not be possible toconduct the planned dilation and curettage hysteroscopy."

How should I report this?

Georgia Subscriber

Answer: Your best bet would be to report 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) with modifier 22 (Increased procedural service).

Watch out: Although your physician thinks the problem might be a fibroid, you don't have any pathology evidence of this fact. You also don't have any description that would allow you to bill the vaginal approach myomectomy code (58145, Myomectomy, excision of fibroid tumor[s] of uterus, 1 to 4 intramural myoma[s] with total weight of 250 grams or less and/or removal of surface myomas; vaginal approach) in the office setting.

Also, you should not use 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/ or polypectomy, with or without D&C) with modifier 52 (Reduced services), because this physician never started the hysteroscopy procedure. He did not place the hysteroscope; rather, he removed part of a solid lesion.