Ob-Gyn Coding Alert

Question: Our physician performed a video hysteroscopy for abnormal uterine bleeding. During the procedure, he noted a submucous uterine fibroid, which he could not remove at the time. Instead, he took a biopsy of the fibroid and submitted it for pathologic evaluation. Because he used an excision to remove a portion of the fibroid, should I report this as 58561 or 58558?

Indiana Subscriber

Answer: In this case, you should report 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C). By definition, a biopsy is the excision of tissue for diagnostic pathologic examination.

The amount of tissue removed does not impact the purpose of the excision. Your ob-gyn began the procedure as a diagnostic hysteroscopy, but in the process noted the fibroid and determined that it could not be removed. Consequently, he performed the biopsy.

For you to bill 58561 (... with removal of leiomyomata), the surgeon would have to remove the entire fibroid, which was not the case here.