Ob-Gyn Coding Alert

Question: Our office has started doing sonohysterograms. We were told by the rep that if our ob-gyn sees a patient for menometrorrhagia, and had a biopsy, sonohysterogram and ultrasound, our coding should be as follows: 58340 linked to 626.2, 58100 linked to 626.2, and 76831 linked to 626.2. Is this correct?


Colorado Subscriber


Answer: Your diagnosis of 626.2 (Excessive or frequent menstruation) is correct. And the code for the sonohysterogram is certainly 58340 (Catheterization and introduction of saline or contrast material for saline infusion sonohysterography [SIS] or hystero-salpingography).

If your physician also did the transvaginal ultrasound and interpretation after the ob-gyn injected the saline, he can bill that too. You-ll use the code you listed: 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). 

And of course, 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]) is for an endometrial sampling. 

Important: The code order would be 58340, 58100-51 (Multiple procedures), and 76831. All of these codes link to 626.2. If you are not using your machine for the ultrasound portion, you should add modifier 26 (Professional component) to 76831.

Don't miss: You won't add modifier 51 to 76831 because this is not a multiple procedure but a diagnostic service. Normally, you do not need modifier 51 for this type of service.