Wiki Unsucessful myomectomy

[kellyg]

I would like some input on the correct coding option for a hysteroscopic myomectomy which was not successful. The provider documented that the fibroid was able to be detached from the uterus at the stalk but was unable to remove it from the endometrial cavity. It appears that a small portion of the fibroid was removed and sent to pathology. After multiple attempts at removal she stopped the procedure. Would procedure code 58561 need to be billed with modifier 53 or 52?

 

[Annmarie4412]

I would say 58561 with the 52 modifier.

 

[kellyg]

Thank you for your input! I feel that may be the best route as well given a small portion of the fibroid was removed.

 

[Annmarie4412]

When I think of these modifiers, I think of the following to help make my decision:

52: Is the procedure being reduced due to unsuccessful attempts?
53: Is the procedure being discontinued due to complications (patient is not tollerating the procedure such as IUD placement, puncture of the uterus while sounding etc)

Thank you for your input! I feel that may be the best route as well given a small portion of the fibroid was removed.