Sunday, April 24, 2011

Hysteroscopy - a view from the inside

Here's the info that I put out on Hysteroscopy. I will be following up with Hysterectomy info soon... Happy Coding : )

Hysteroscopy – A view from the inside

A hysteroscopy is not the same as a hysterectomy. The two words sound very similar, but are two very different clinical procedures. Physicians utilize both type of procedure to diagnose and treat uterine symptoms and disease.

Definition: Hysteroscopy: A visual instrument (scope) inspection of the uterine cavity.

Pronunciation: his′ter-os′kŏ-pē Synonym: uteroscopy

CPT has given hysteroscopic procedures their own set of codes. The codes 58555 -58565, are listed just before the laparoscopic procedures in the CPT book.

The hysteroscopic technique is used to look inside the uterus. This procedure is also known as a uteroscopy. With this procedure, the physician has the unique opportunity to view the interior of the uterus. The physician can then decide upon treatment options, based upon direct diagnostic visualization and/or biopsy of the uterus The hysteroscope itself is a small lighted telescopic type device that is placed inside the uterus via entrance through the vagina and cervix. This scope can also accommodate different tools to enable the physicians to diagnose and surgically treat symptoms and diseases of the uterus.

Diagnostic and treatment options with the hysteroscope can include:

§ Uterine biopsy,

§ Uterine ablation

§ Lysis of adhesions within the uterus

§ Uterine dilatation curettage (D&C)

§ Removal or destruction of endometrial polyps

§ Removal or destruction of endometrial tumors

§ Introduction or removal of foreign bodies within the uterus

§ Sterilization procedures .

When using the scope, the uterus is also inflated with gas or fluid to enable the physician to get a better view of the entire uterine cavity. This gas or fluid is commonly referred to in the operative or procedure record as the ‘distending media’.

Hysteroscopy can be performed in the physician’s office or as an outpatient procedure in the hospital. It’s a fairly quick procedure, as normally takes approximately 30 minutes to perform. When a hysteroscopy is performed in the office, the patient is given oral pain relievers prior to the procedure, in addition to a local anesthetic applied or injected to the cervix and vaginal area. When a hysteroscopy is performed in the hospital outpatient setting, conscious sedation, or general anesthesia may be used.

Coding for hysteroscopy requires an understanding of the hysteroscopic procedure itself, the CPT code definition, and the ICD-9 diagnosis code set. Coder diligence in choosing these procedure and diagnosis code(s), will ensure correct billing of claims to the insurance carrier or 3rd party payers.

Let’s get technical….

In the CPT book, code 58555 Hysteroscopy, diagnostic: is described as a detailed viewing of the uterus to diagnose either a symptom or disease of the uterus. When coding a diagnostic hysteroscopy, this code is ‘bundled” with CPT codes 58558- 58563. No other hysteroscopic procedure is performed. Code 58555 is a very straightforward code, encompassing ONLY a diagnostic viewing of the uterus.

The verbiage in the next listed hysteroscopy CPT code can confuse a coder. The CPT Code 58558 for hysteroscopy includes a sampling (biopsy) of the endometrium; and/or a polypectomy, and it also states with or without a D&C (dilatation and curettage) of the uterus. The interpretation of this code requires a coder to carefully review what the code definition is stating. The confusion comes, in part, to the CPT descriptor referring to “and/or polypectomy” in addition to “with or without a D&C”. Many coders make the mistake of wanting to bill for a separate D&C or a separate polypectomy. The CMS CCI edits have many of these codes bundled together. It is inappropriate to code or ‘unbundle’ these codes.

The next hysteroscopy codes listed in CPT are: 58559,58560, 58561 and 58562. CPT is very specific in the descriptor of these 4 codes. Coders have a directed diagnosis reference with the usage of the hysteroscopy code. When coding for the above hysteroscopy procedures, it is critical that the diagnosis appended corresponds correctly to the cpt code. In addition, a coder should review the pathology report and operative documentation when choosing the diagosis code.

Coding confusion can also happen with code 58563; Hysteroscopy with endometrial ablation. It is easily confused with CPT code 58353 Endometrial ablation, thermal, without hysteroscopic guidance. Coders need to be diligent and carefully review the physician’s operative/procedure documentation closely to determine if the hysteroscope was utilized in the procedure. Many physician offices perform a thermal endometrial ablation without using the hysteroscope.

Code 58563 can also be used when the physician performs an endometrial resection. Documentation for this procedure, is notated by the usage of the resectoscope tool by the physician in the operative record. Diagnoses such as endometriosis, excessive menstruation, or abnormal uterine bleeding can be treated with the resectoscope.

The last code in the ‘hysteroscopy’ section of CPT is code 58565. This hysteroscopic procedure specifically states “Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants” What this procedure does is induce reproductive sterilization. The hysteroscope is used to place small foreign body implants into each of the fallopian tubes. The implants help create scar tissue buildup within the fallopian tube thereby blocking entrance of the egg to the uterus,. Code 58565 specifically states this procedure is to be performed as a bilateral procedure. However, if the procedure is only performed on 1 tube or unilaterally, then a modifier 52) should be appended to denote the reduced service.

With all hysterosopic procedures the procedures listed below are always included (or bundled) with them.

§ Bladder Catheterization

§ Examination under anesthesia – which includes visualization of the vagina & cervix

§ Application of a tenaculum and dilation of the cervix, or cervical canal

§ Insertion of the hysteroscope and distending media such as gas or fluid

§ The inspection of the uterine cavity

§ Injection or placement of local anesthesia, conscious sedation, or application of a nerve block used for anesthesia.

§ Removal of instruments, catheters or drains,

§ Photodocumentation and the operative report documentation

Wrap up with the reports….

The two operative reports below, give coders an idea of what may be documented in an outpatient hospital record for the hysteroscopy procedures.

Operative Report #1:


POSTOPERATIVE DIAGNOSES: 1. Hypermenorrhea. 3. Secondary anemia

PROCEDURE PERFORMED: 1. Dilatation and curettage. 2. Hysteroscopy.

GROSS FINDINGS: Uterus was anteverted, greatly enlarged, irregular and firm. The cervix is patulous and nulliparous without lesions. Adnexal examination was negative for masses.

PROCEDURE: The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a tenaculum. The uterus was sounded to a depth of 11 cm. The endocervical canal was then progressively dilated. The hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera. The endometrial cavity was distended then visualized.. A moderate amount of proliferative endometriosis was noted. There were no direct intraluminal lesions seen. The patient tolerated the procedure well. Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.

A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathology for analysis. The instruments removed and accounted for. Patient sent to recovery, satisfactory post-op condition.

CPT Code:

ICD-9 Dx


617.0 Endometriosis of Uterus

626.2 Hypermenorrhea

285.9 secondary anemia

Operative report #2

PREOPERATIVE DX: 1. Desires permanent sterilization.

OPERATIVE PROCEDURE: Hysteroscopy with tubal occlusion

ANESTHESIA: General with paracervical block. ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None. PATHOLOGY: None. DISPOSITION: Stable to recovery room.

PROCEDURE: The patient was taken to the operating room, where general anesthesia was found to be adequate. She was prepped and draped in the usual sterile fashion. A speculum was placed into the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum and a para-cervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.

The cervical vaginal junction at the 4 o’clock position was injected and 5 ml was instilled. The block was performed at 8 o’clock as well with 5 ml at 10 and 2 o’clock. Lidocaine was injected into the cervix. The cervix was minimally dilated. The 5-mm 30-degree hysteroscope was then inserted under direct visualization using the lactated ringer’s as a distention medium. The uterine cavity was viewed and tubal occlusion device was then inserted through the operative port. The tip of the occlusive device easily slid into the right ostia of the fallopian tube. The coil was advanced and easily placed. The device was withdrawn. There were three coils protruding into the uterine cavity after removal of the insertion device. The insertion device was removed and reloaded. Procedure was then repeated with the same results on the left tube. Again, three coils protruding into the uterine cavity. The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.

CPT Code:

ICD-9 Dx


V25.2 Sterilization