Ob-Gyn Coding Alert

Question: The ob-gyn cauterized a Nabothian cyst located just on the surface of the cervix. He performed this service after removing the hysteroscope. Should I include the cauterization of Nabothian cyst with the hysteroscopy dilation and curettage (D&C) 58558?

Answer: No, you should not normally include this service in the hysteroscopy D&C (58558) because that code includes polyps found inside the uterus, and this was cyst on the cervix. But you won't find a perfect code for this. He did not cauterize the cervix, just a cyst. That means reporting the full 57511service is out as an option. Also, he did not excise the cyst, so 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) is out.

Best Option: You could try 57511-52 (Cautery of cervix; cryocautery, initial or repeat; Reduced services) because your physician cauterized a lesion on the cervix.