Ob-Gyn Coding Alert
D&C and Attempted Hysteroscopy
Question: My ob-gyn documented the following:
dx: post menopausal bleeding and stress incontinence.
Weighted speculum was placed into vagina. Sims retractor used. Cervix was grasped. Cervical Dilation was then attempted utilizing cervical dilators. Due to Cervical Stenosis could not be completed. Hysteroscope was attempted. That failed so surgeon opted for sharp curettage. Endometrial and endocervical curettings were obtained.”
I’m thinking I should report 58120 For the D&C, but I’m not sure how to code attempted hysteroscopy. What should I do?
“Dilation and curettage, attempted hysteroscopy.
California Subscriber
Answer: You should code this as 58120-22 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]; Increased procedural service). You should include the endocervical curettage in 58120. Modifier 22 represents the additional work in trying to use the hysteroscope (just like you would with any converted procedure). In linking the diagnostic reason for the procedure, do not list stress urinary incontinence with this procedure as it may result in a denial. The medical indication for a D&C would be the postmenopausal bleeding.
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