Wiki failed endometrial biopsy documentation

[debellis59]

Hi!

I have a provider that wants to bill out for a failed endometrial biopsy, which I have no problem with except ....

He did not document the biopsy and is stating that it says under "Cervical Stenosis" why it was stopped. This is his "note:"
"Cervical stenosis (uterine cervix): Failed EMB today. If further endometrial sampling indicated in future, would benefit from cervical ripening w/ Misoprostol and use of lacrimal duct dilators."

He does still need to document the procedure, yes?

I just want to be sure before I go back to him.

Thank you.

 

[natashalage]

Hi, I am not an expert yet, but since MD didn’t do the procedure, I would not code it. If MD at least did a half of the description of CPT and encountered obstacles, then I would code it with a modifier 53.

 

[debellis59]

Hi, I am not an expert yet, but since MD didn’t do the procedure, I would not code it. If MD at least did a half of the description of CPT and encountered obstacles, then I would code it with a modifier 53.

That's what I figured too. He does say in a note to me that he started it, but gave no description in the chart note. Thank you.