Wiki How to code the following? I get conflicting answers from supervisor

[icljones]

A speculum was used to visualize the cervix. The cervix was grasped with a single tooth tenaculum at 12 o'clock and then dilated with an os finder. 1mL of lidocaine was instilled into the cervical canal and uterine cavity. The uterus was then sounded to 9 cm with the endometrial pipelle and a specimen was obtained in 3 passes yielding a moderate amount of tissue.

The Endosee hysteroscope, with water running, was then passed into the uterus under direct visualization and without perforation. The cavity was visualized with fluffy, normal endometrium without pathology. Normal patent ostia were visualized. The hysteroscope was removed.

The tenaculum was removed from the cervix.

 

[antoniamay]

This sounds like 58558 to me, but I am not an OB coder. What is the discrepancy of codes you are discussing?

 

[icljones]

This sounds like 58558 to me, but I am not an OB coder. What is the discrepancy of codes you are discussing?

58558 vs 58100 biopsy done before hysteroscopy inserted. Both have been marked incorrect on my audit.

 

[antoniamay]

58100 doesn't appear appropriate to me because its without cervical dilation. So they have not advised you the appropriate code? I still think its going to be the 58558. I wish I was more helpful

 

[natashalage]

hello, I am not an expert but maybe CPT 58120. check out its description. it has dilation of cervix and curettage of the endometrial lining. hysteroscopy was probably to check if no injury is done= not coded.

 

[csperoni]

As @natashalage stated, it depends why the hysteroscopy was performed. If the hysteroscopy was part of the procedure, then I would code as 58558. If the hysteroscope was used just to check your work, then not coded an 58120.
The way it was worded does seem to indicate they did the procedure, THEN the hysteroscopy, but not why.