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:
PREOPERATIVE DIAGNOSES: 1. Hypermenorrhea.
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 |
| 58558 | 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 |
| 58565 | V25.2 Sterilization |
Hello Lori-Lynne - I have been told by my providers to bill paracervical block with all hysteroscopy codes for non-medicare patients even thought I told them that CCI edits bundle them together. So I append modifier 47 to hysteroscopy codes(58555-58565) and modifier 59 to 64435. Is this incorrect?
ReplyDeleteThe paracervial block in "bundled" by Medicare patients, butif you are billing a non-government 3rd party payer, they may be willing to accept this. However, most 3rd party payers will abide by the CCI edits for bundling. Unless you truly have medical necessity and separately identifiable resons for the paracervical block, I would not bill it.
DeleteOur physician performed Hyst with "removal of adhesive band"...Would you be able to confirm if I should use 58558, hyst with loa?
ReplyDeleteI would look at using the code of 58559 if the adhesive band is probably more of an adhesion that is intrauterine and that would need to be removed hysteroscopicall. : )
DeleteDo you know if CPT 58558 is inclusive to 58561?. Its not listed as inclusive on the NCCI Edit website but BCBS wont pay them both together.
ReplyDeleteThanks!
The two codes 58558 and 58561 are not bundled, but if your carrier does not want to pay them, you should appeal and be sure to add a mod 59 to the second procedure. You may also want to contact the carrier, as they may not necessarily have to follow CCI edits, and have their own bundling edit software that they use. Only CMS is contractually bound to use the CCI edits.
ReplyDeleteHi Lori-Lynne,
ReplyDeleteI am so glad I found your website. I am a coding student and I am coding for the first time complete documentation. came across an operative report (hysteroscopy) but the hysteroscopy was converted to hysterectomy because of perforation of the uterus. It was then discovered that the patient had a porcelain gallbladder which required another physician to come to the operating room to assess and doctor #2 performed a cholecystectomy after doctor #1 finished the hysterectomy. My question is do I code for the hysteroscopy and what modifiers are appropriate for this scenario?
Again I am glad I found your website.
Sincerely,
Patty
Hi Patty - I would need to see the complete documentation, but from what you've stated here, you would bill the hysteroscopy with modifiers 51 (and possibly 59 depending on the ins carrier) and you would bill your hysterectomy as the first procedure. The caveat to this is the diagnosis - and determining if the uterine perforation was due to the hysteroscopy, or if upon the scope of the hysteroscopy, it was found the uterus was already perforated... The diagnosis will also help "paint the picture" for the insurance carrier. If you need more guidance or info, please e-mail me at webbservices.lori@gmail.com and I'd be happy to help you out.
DeleteIf physician removes hysteroscopy before doing endometrial ablation and then puts it back in after removing ablation device.. do you still code this as hysteroscopy with ablation.
ReplyDeleteYes, you would only bill the one "ablation" code, as a diagnostic hysteroscopy is bundled with the ablation.
DeleteBack to hysteroscopy with ablation.. do you still consider the ablation to be with "hysteroscopic guidance" if the scope is removed before putting in the ablation device. Code 58563.
ReplyDeleteIf the hysteroscope is removed prior to doing the ablation, then I would code the hysteroscopy code of 58563. as the scope allowed the viewing, and then the ablation tools used for ablation. Whereas code 58353 ablation w/o hysteroscopic guidance the scope is not utilized at all.
DeleteHello,
ReplyDeleteI really need some clarification on billing out a office Hysteroscopy 58555. I work for a infertility doctor who usually does this prior to the patient starting any treatment. I have come across a couple of patient's whose Preoperative Diagnosis is: Recurrent Pregnancy Loss 629.81 but Postoperative is: Normal Uterus. Can we bill the Insurance with the diagnosis code of 629.81 or what code can I use for Normal Uterus? We usually use 628.9 when the uterus is normal. Please help? Thanks
The diagnosis code of 629.81 is denoted as "habitual aborter without current pregnancy" Even though the patient has a normal uterus, the reason /eg medical necessity IS that the patient is a habitual aborter, w/out a current pregnancy. Yes, you should bill the insurance carrier for the correct diagnosis.
DeleteHow do you bill true clear op hysterscopy?
ReplyDeleteA True Clear hysteroscopy is simply the "brand name" of the hysteroscopy tool itself. (eg like Coke, Pepsi, etcc) However, the coding is still coded based upon the CPT codes, not the brand of the hysterocopic tool that is/was being used.
DeleteHelp! I've been coding for years but an new to OB/GYN. I second guess myself all the time on this one:
ReplyDeleteHysteroscopy, D&C and ablation. Is CPT 58563 the correct code? I always question if this includes the D&C because of where the semicolon is in the description.
Thank You Lori-Lynne!
DeleteYes, the D&C is bundled with the ablation (in code 58563) No second guessing needed. You are correct!
ReplyDeleteOur doc did a Hysteroscopy Ablation and polypectomy. Would you just bill the 58563?
ReplyDeleteIn response to your question, the billing of a polypectomy at the time of a hysteroscopy would depend on where the polyp was located, and what method of removal was used ...
DeleteLori-Lynne, I have the same question as Anonymous. My op report states "It was noted the patient had an endometrial polyp coming from the posterior aspect of the uterus, near the cervix. At this time the hysteroscope was removed, polyp forceps were placed, the polyp was grasped and removed."
DeleteThis was during a D&C with ablation. Should 58558 be added along with 58563? THANKS for any help.
I need some clarification on billing 58558 versus 58555 with 58120. Per the note speculum was placed, paracervical block obtained, uterus sounded. cervical canal dilated. the hysteroscope was inserted and cavity was visualized. The hysteroscope was removed and the uterus was then gently curetted until a gritty texture was removed. All instruments removed. Do I bill this as a 58555 and a 58120 or a 58558 since he/she removed the scope before performing the curretage and did not go back in with the scope after the curregate.
ReplyDeleteThanks for any input.
Hi there - You will only want to bill the 58558 and not "unbundle" the CPT code. The combined CPT code already includes the work for with/without a D&C. As per the ACOG guidelines, the "intraoperative" services for code 58558 include a D&C (any method)
DeleteLori-Lynne,
ReplyDeleteI work for an insurance company and this questions seems to be coming up more frequently. The provider does a laparoscopy, surgical, with vaginal hysterectomy and D & C. The provider is billing 58550 and 58120. Would you recommend payment of 58120?
Thank you!
According to the CCI bunding edits - the code 58550 and code 58120 are considered "bundled" with each other, and the edits do not allow for an over-ride with a 59 modifier. CMS, and the majority of the large 3rd party payers subscribe and adjudicate based upon the CCI edits and do not allow payment for those two services when performed at the same operative/procedural session. L :)
ReplyDeleteDoes 58558 include a cervical punch bx or should 57500 also be billed with 58558?
ReplyDeleteThese codes are separately identifiable. the 57500 is not bundled with the 58558 so you should bill for both if both were documented appropriately.
ReplyDeleteIf physician removes hysteroscopy before doing endometrial ablation and then puts it back in after removing ablation device See More....http://www.pearlwomenshospital.com/office-hysteroscopy/
ReplyDeleteWhat about removal of IUD (58301)with Hysteroscopy with ablation (58563), when would it be appropriate to append modifier -59, CCI edits state it can be unbundled with a modifier?
ReplyDeleteIn regard to the IUD removal.. the code 58301 does not specify "how" the removal is performed (eg via scope, or assistive device) so yes, you should bill the 58563 ablation as the primary procedure, then the IUD removal with a modifier 59 as "separately identifiable procedure". You may have to appeal this, as you certainly can't do an ablation if the IUD is still in place. However, some carriers will argue that this is precisely why it is "bundled" . Good Luck. I've had success on both side.
DeleteI'm billing a polypectomy with versapoint, would I still use 58558?
ReplyDeleteThe polypectomy is the procedure, the versapoint is the "tool or equipment" used to perform the procedure. so regardless the 58558 is still used to designate a polypectomy was performed... it does not specify with what "tool" it has to be performed with.
ReplyDeleteI am second guessing myself on my coding. My physician performed a hysteroscopy ablation and a tubal ligation, my first thought is to bill as 58563 and 58671-51. Would this be correct?
ReplyDeleteIf a hysteroscopy is performed and endometrial polyps are removed with a TRU Clear hysteroscopic morcellator and then an endometrial ablation is performed are the two billed as separate procedures?
ReplyDeleteHi AJB - As per the CCI bundling edits these two codes are "bundled" as the polypectomy and the ablation are components within the ablation code. They cannot be over-ridden with a 59 mod as two separately identifiable procedures, if performed at the same time on the same dayl.
ReplyDeleteI need the code for hysteroscopic myomectomy and d&c without endometrial ablation as the ins co will not cover unless d & c is performed as an alternative. Can't find the code without the ablation.
ReplyDeleteHi LPC - The code you would want to use is code 58561. this is the hysteroscopy with only the removal of a leiomyomata (aka myoma) the carrier should be willing to pay under this code. L :)
DeleteHI- NOT SURE IF I SHOULD USE CODE 58558. HYSTEROSOPY DILATION & CURETTAGE
ReplyDeleteUTERUS SOUNDED TO 8 cm AND WAS SUFFICIENTLY DILATED. SEVERAL ATTEMPTS MADE TO FLUSH THE UTERUS FOR BETTER VISUALIZATION. HOWEVER , DUE TO BLEEDING , THE HYSTEROSCOPY WAS SUBOPTIMAL. NO POLYP COULD BE VISUALIZED . CURETTAGE WAS PERFORMED AND CURETTING SENT TO PATHOLOGY
Yes, you should bill this with code 58558. Rationale: All components of the procedure were performed, it was just that the physician noted that visualization was suboptimal, and no polyp was visualized. Therefore, it is still appropriate to only bill for the scope + D&C. In addition, the 58558 code states D&C "and/or" polypectomy. So you are correct to code the 58558.
DeleteHI, I NEED HELP. THIS PATIENT IS HAVING ESSURE DONE WHICH I AM GOING TO USE CPT CODE 58565 BUT AT THE SAME TIME THE DOCTOR IS GOING TO REMOVE HER IUD, WOULD THAT BE A SEPARTE CODE?
ReplyDeleteYes, you would code the IUD removal with the code 58301-51. You will need to use the mod -51 to denote the 2nd procedure performed at the same operative session.
ReplyDeleteHi Lori-Lynne, I don't have a question about a hysteroscopy but my question is for a hysterectomy. my doctor is going to do a robotic hysterectomy, bilateral salpingectomy and a ovarian cystectomy possible unilateral or bilateral oophorectomy. For the robotic hysterectomy I am going to use cpt code 58571 but do I use cpt code 58662 for the ovarian cystectomy or is it included in cpt code 58571?
ReplyDeleteHi Lori-Lynne,
ReplyDeleteI have a question about surgery done in the surgery center laparscopic tubal cautery with a Hysteroscopy removal of an IUD due to strings missing. How would I code this? The IUD was not impacted and a Caiman sealing device was used on the fallopian tubes ( a partial salpingectomy was done.) Is this coded with 58670 and 58301 or 58562? Thank you so much for your help!!!
Hi Lori-Lynne,
ReplyDeleteI have a question about surgery done in the surgery center laparscopic tubal cautery with a Hysteroscopy removal of an IUD due to strings missing. How would I code this? The IUD was not impacted and a Caiman sealing device was used on the fallopian tubes ( a partial salpingectomy was done.) Is this coded with 58670 and 58301 or 58562? Thank you so much for your help!!!
Hi,
ReplyDeleteI have a question, would you just bill 58563 or can you bill 58563 & 58120 with mod 51 Procedure was: D&C, Hysteroscopy, and NovaSure endometrial Ablation. Hysteroscope was advanced into uterine cavity and explored it was found to be WNL. Sharp curettage was then performed to obtain uterine sample and the NovaSure device was then inserted and the ablation was then performed. Novasure device was removed and hysteroscopy was again performed showing ablated uterine tissue. Thanks for your help
With hysteroscopy - the 58120 IS considered bundled with the 58563, so you can only bill the 58563. If you bill both, and append a 51 and/or a 59 modifier you will get a bundling denial from the payers. (Not just CMS, but nearly all payers considered these two procedures as a bundled service.) In addition, the 58563 is an indented code under CPT code 58558, which shows that it "includes" the D&C.
DeleteCan you bill ultrasonic guidance when doing a hysteroscopy?
ReplyDeleteYou can bill for ultrasound guidance under the code of 76998(26) IF, and only IF the ultrasound was performed as a separately identifiable procedure and you have a documented interpretation for it that supports the medical necessity of u/sound at the time of the hysteroscopy. . The hysteroscopy is normally all that is performed.
ReplyDelete