A little stumped w/ what CPT's to use. I'm not sure if I should code the following Op Note as 58563 w/ mod 52 along w/ code 58558 or just code 58558 w/ mod 22. I know 58558 bundles w/ 58563, if 58563 is completed, but in this case it was not, so is it possible to bill the discontinued procedure w/ modifier 52 and also completed procedure 58558? Help.
ANESTHESIA: General.
PREOPERATIVE DIAGNOSIS: Menorrhagia.
POSTOPERATIVE DIAGNOSIS: Menorrhagia.
PROCEDURES PERFORMED: Hysteroscopy; dilation and curettage; attempted NovaSure endometrial ablation with failure of cavity assessment, failure of additional cautery to assess or remove the endometrial lining.
COMPLICATIONS: Cavity on initial assessment showed bicornuate structure. NovaSure did not complete the cavity assessment. In addition, an attempt at rollerball cautery was not propagated.
FLUIDS: 1700 cc of crystalloid.
ESTIMATED BLOOD LOSS OF PROCEDURE: 50 cc.
HYSTEROSCOPIC FLUID: 1700 cc with a deficit of 185.
PROCEDURE IN DETAIL: The patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in normal sterile fashion and bladder was cleared of approximately 100 cc of urine. Weighted speculum was then inserted vaginally. Anterior lip of the cervix grasped with a tenaculum. The uterine sound was used for a sound of approximately 5. The hysteroscope was then introduced. It was noted the patient did have a bicornuate uterus but normal-appearing tubal ostia bilaterally. This was removed. The NovaSure device was then tested with appropriate expansion of the device. The cervix was then dilated to approximately an 8 Hegar. The NovaSure was introduced. The cavity assessment had been identified at 5.5. With feeding of the device, the width was initially noted at 3.5. Upon initial attempt after seating the device and advancing the cervical cap, the cavity assessment failed. There was 1 disconnected tubing. This was reconnected but additional cavity assessment failed possibly due to bicornuate structure. This instrumentation was then removed. The resectoscope was then introduced, and the uterus dilated with solution. An attempt to use rollerball cautery was unsuccessful. Cautery was not transmitted. A sharp D and C was then performed and pathology was sent. Final fluid was 1700 cc with a 185-cc deficit. All instrumentation was removed from the vaginal canal. All sponge, lap, and needle counts were correct x2, and the patient was transferred to recovery in stable condition.
Appreciate the help.
ANESTHESIA: General.
PREOPERATIVE DIAGNOSIS: Menorrhagia.
POSTOPERATIVE DIAGNOSIS: Menorrhagia.
PROCEDURES PERFORMED: Hysteroscopy; dilation and curettage; attempted NovaSure endometrial ablation with failure of cavity assessment, failure of additional cautery to assess or remove the endometrial lining.
COMPLICATIONS: Cavity on initial assessment showed bicornuate structure. NovaSure did not complete the cavity assessment. In addition, an attempt at rollerball cautery was not propagated.
FLUIDS: 1700 cc of crystalloid.
ESTIMATED BLOOD LOSS OF PROCEDURE: 50 cc.
HYSTEROSCOPIC FLUID: 1700 cc with a deficit of 185.
PROCEDURE IN DETAIL: The patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in normal sterile fashion and bladder was cleared of approximately 100 cc of urine. Weighted speculum was then inserted vaginally. Anterior lip of the cervix grasped with a tenaculum. The uterine sound was used for a sound of approximately 5. The hysteroscope was then introduced. It was noted the patient did have a bicornuate uterus but normal-appearing tubal ostia bilaterally. This was removed. The NovaSure device was then tested with appropriate expansion of the device. The cervix was then dilated to approximately an 8 Hegar. The NovaSure was introduced. The cavity assessment had been identified at 5.5. With feeding of the device, the width was initially noted at 3.5. Upon initial attempt after seating the device and advancing the cervical cap, the cavity assessment failed. There was 1 disconnected tubing. This was reconnected but additional cavity assessment failed possibly due to bicornuate structure. This instrumentation was then removed. The resectoscope was then introduced, and the uterus dilated with solution. An attempt to use rollerball cautery was unsuccessful. Cautery was not transmitted. A sharp D and C was then performed and pathology was sent. Final fluid was 1700 cc with a 185-cc deficit. All instrumentation was removed from the vaginal canal. All sponge, lap, and needle counts were correct x2, and the patient was transferred to recovery in stable condition.
Appreciate the help.