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Pt presented with complaint of: 'tissue hanging from her vagina that's stuck.' Pt is She is 2 mo. s/p a hysteroscopy, D&C, & rollerball on 5/18 d/t menorrhagia and fibroids. Sono showed: large fibroid (8.18, was 7.65 mm at largst last sono on 4/11) seen, EC was 9.1 mm, very difficult to distinguish d/t fibroid artifact.
Upon Exam IN OFFICE w/no anesthesia a large mass of soft fleshy rubbery material was removed from cervix with ring forcep, sent to path urgent. She likely had a prolapse of a submucous fibroid. Pathology confirmed it was 218.0 submucous leiomyoma of uterus .
Looking at past questions, I offered my doc CPT code 58145 as best fit for this, or if she was uncomfortable with this, go with unlisted procedure code 58999 and send with records. She doesn't want either, and insists there must be something else. Can anyone offer anything else for her? Thank you.
Upon Exam IN OFFICE w/no anesthesia a large mass of soft fleshy rubbery material was removed from cervix with ring forcep, sent to path urgent. She likely had a prolapse of a submucous fibroid. Pathology confirmed it was 218.0 submucous leiomyoma of uterus .
Looking at past questions, I offered my doc CPT code 58145 as best fit for this, or if she was uncomfortable with this, go with unlisted procedure code 58999 and send with records. She doesn't want either, and insists there must be something else. Can anyone offer anything else for her? Thank you.