Wiki Hysteroscopic removal of leiomyomata and D&C denials!!

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Teri Johnson

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Can anybody tell me how to get 58561 and 58558/51 paid when both are done? It does not hit an NCCI edit yet I have gotten denials from the Blues, Health Partners and Preferred One saying 58558 is incidental or part of the more extensive procedure 58561! I appeal with notes showing both procedures are done and describe how they are to pay according to the multiple endoscopy rule. It seems to fall on deaf ears, what can I do?
 
Endometrial sampling, polypectomy ( more or like the same as leomyomata polyps/ mass), and D& C are becoming component/part of the major procedure of hysteroscopic removal of leomyomata during the same session.
You can code only 58561.
If extensive time consuming and incresed work than the usaual, try to give modifier 22
 
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I'm also experiencing these denials.
@Preserene - where are you finding the information that you can only code 58561. I haven't seen that referenced yet. Doing a D&C or Bx would almost always involve more work/time than just removing the leiomyomata therefore adding Mod-22 would be a good option assuming the note supports.
 
Leomyoma is a Fibroid uterus and fibroids (LEOMYOMATA) may be submucosal, intramural, intestitial, pedunculated and so on(Yet another one at the serosal (peritoneal side) which you can get to see with lap. or open or by US.) .
We are dealing about those in the cavity aspect of the uterus.
The removal of any of these fibroids ( which becomes integral part of the uterine tissues by pathology, is not an easier procedure and they are considered as major surgical procedures, since long even before the advent of hysteroscopy.

D&C is always considered a minor procedure and it is procedurally too( it just means scraping of the endometrium only (does not reach the myometrium) whereas FIBROIDS, involve endometrium and myometrium, deeper penetration/ excision of the mass from the uterine layers, and the bigger and deeper the mass, the removal is with more intricacy & cumbersome with more bleeding involving the more vessels and blood supply &ligation of bleeding vessels and so on are mandatory .
When a major surgery is performed laprascopically/ endoscopically the minor procedure in that same site with the same entry and in the same session is considered an integral part of that major procedure.
 
I agree with Preserene. Even though CCI edits don't flag the 2, all insurance carriers consider the 58558 to be incidental. McKesson has a claim check tool that gives good explanations for bundled codes. I ran the 2 codes through their editing tool, and sure enough they disallow the 58558. Here's their explanation:

Procedure 58561 is used to report a hysteroscopy with the removal of leiomyomata. A hysteroscopy provides direct visualization of the canal of the uterine cervix and the cavity of the uterus using a lighted endoscope and constant irrigation for optimal view. Leiomyoma, which are benign tumors of the intrauterine cavity, are removed by a shaving technique and a loop electrode to control bleeding. The removal of myomas is effective in the treatment of excessive uterine bleeding during menstruation (menorrhagia).

Procedure 58558 is used to report a hysteroscopy with biopsy of the endometrium and/or polypectomy, with or without dilatation and curettage (D&C). Hysteroscopy provides direct visualization of the endocervical canal and uterine cavity. The hysteroscope is inserted through the vagina and cervix into the uterus, and the physician then removes a sampling of the uterine lining and or a growth within the uterus. The performance of a D&C, to provide a more complete sampling of the uterine lining, may accompany this procedure.

Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure.

CPT codes include verbiage such as simple/complex, limited/complete, superficial/deep, partial/total in several of their procedure descriptions. When similar or identical procedures are performed, but are qualified by an increased level of complexity, only the definitive, or most comprehensive, service performed should be reported. This logic is supported by the CMS guideline for More Extensive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "...the less extensive procedure is included in the more extensive procedure."


Therefore, procedure 58558 is not recommended for separate reimbursement when submitted with procedure 58561.

Becky, CPC
 
Wow, Becky, it is an awesome contribution from you. I had been with some verbal constipation and you have brought forth the concept in a wonderful way with all proof and documentations. Thank you very much.
 
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