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Posted By Gracie Ermitano on 02-27-2018, 01:15:58 in Ob-Gyn
Hi Melanie, i would like to ask your coding suggestion for the above procedures. I have chosen 58999 for the evacuation procedures, 56700 for the hymenectomy and 58180 for the dilation and suction curettage of the uterus in a case of an 11 year old girl with a complete imperforate hymen. Examination under anesthesia (bundled procedure and can't be reported) revealed a bulging vaginal outlet and complete imperforate hymen. Incisions performed on 2 o'clock, 4 o'clock, 8 o'clock and 10 o' clock positions on the hymenal ring and dark copius blood oozing out. This was evacuated using suction device. 500 ml of old hemosiderin stained blood was collected. Provider also stated she needed to dilate the cervix to ease the evacuation and suction curettage of the inside of uterus. Can we also bill for an intraoperative ultrasound done to check and verify if the hematometra and hematocolpos were resolved? Thank you for your feedback. Very respectfully, Gracie
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Posted By Melanie Witt on 02-28-2018, 17:01:07
I would have to say that you should not bill for the evacuation as it is a natural occurrence once the hymenectomy was performed and would also be covered when doing the D&C. Since cervical dilation was required you would report 58120 (not 58180 which is the code for a supracervical hysterectomy so I assume this was a typo :))) And yes you can bill for the intraoperative ultrasound, but you may one of two options: 76998 if is was used during the D&C to provide guidance in evacuating the blood, but if it was done to check that the procedure was successful, guidance no longer applies and in fact the payer may decide not to pay at all because it was checking her work. Alternatively this could constitute a follow-up study (assuming an original one was performed prior to the procedure - 76970) or if this was a diagnostic study following the D&C you would go with the gyn ultrasound code TV or TA that meets the criteria based on the documentation. Remember that a hard copy image is still required even if it was guidance and also a written interpretation for guidance, follow-up or a new study.
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