Hi All:
I've got a tricky one here--
The patient was being treated for menorrhagia and desired permanent sterilization
Briefly, the Op note states
a laparoscopic LT salpingectomy (RT was removed years ago)-- I used CPT 58671-LT
then, a diagnostic hysteroscopy was performed--findings were that the endometrium was thickened preventing clear visualization, so the hysteroscope was withdrawn then a D&C was performed-specimens went to Pathology; then the Novasure device was inserted and ablation was performed; the device was removed and then the hysteroscope was reinserted to inspect the results of the ablation then the hysteroscope was withdrawn with the procedure(s) being terminated.
My coding issue is the fact that the hysteroscope was used twice during this procedure, but not used for the Novasure/thermal ablation procedure. I've been instructed to code the Novasure/thermal ablation with CPT 58353.
I can understand coding the ablation procedure w/o the hysteroscopy--however, the hysteroscope was used twice during the entire operative period.
CCI edits include the D&C with the ablation procedure so I would not code the D&C separately.
Should I be coding the hysteroscopy only once as a diagnostic hysteroscopy CPT 58555 as the second time the hysteroscope was used was to inspect the outcome of the ablation? OR should I code the ablation procedure with the hysteroscopy using CPT 58563?
I am coding for the facility and want to be sure that the use of the hysteroscope is captured.
Any input is greatly appreicated.
Debbie K
I've got a tricky one here--
The patient was being treated for menorrhagia and desired permanent sterilization
Briefly, the Op note states
a laparoscopic LT salpingectomy (RT was removed years ago)-- I used CPT 58671-LT
then, a diagnostic hysteroscopy was performed--findings were that the endometrium was thickened preventing clear visualization, so the hysteroscope was withdrawn then a D&C was performed-specimens went to Pathology; then the Novasure device was inserted and ablation was performed; the device was removed and then the hysteroscope was reinserted to inspect the results of the ablation then the hysteroscope was withdrawn with the procedure(s) being terminated.
My coding issue is the fact that the hysteroscope was used twice during this procedure, but not used for the Novasure/thermal ablation procedure. I've been instructed to code the Novasure/thermal ablation with CPT 58353.
I can understand coding the ablation procedure w/o the hysteroscopy--however, the hysteroscope was used twice during the entire operative period.
CCI edits include the D&C with the ablation procedure so I would not code the D&C separately.
Should I be coding the hysteroscopy only once as a diagnostic hysteroscopy CPT 58555 as the second time the hysteroscope was used was to inspect the outcome of the ablation? OR should I code the ablation procedure with the hysteroscopy using CPT 58563?
I am coding for the facility and want to be sure that the use of the hysteroscope is captured.
Any input is greatly appreicated.
Debbie K