Hysteroscopy D&C with POC, unknown pregnancy

We saw a patient for the 1st time on 6/9/16. Another OB/GYN told patient she needed surgery for an ovarian cyst. Patient has been bleeding since her miscarriage that happened March 28th. The previous doctor did not submit records but indicated the patient has now been diagnosed with menorrhagia.
My doctor dictated she did a Laparoscopy with left salpingostomy and ablation of endometriosis and a hystercopy D&C. She did do the ablation of endometriosis. She did not document enough to reflect a salpingostomy...all she noted was tuboovarion cyst was elevated and linear incision was made to drain contents. I was just going to bill the 58662.

She documented this for the D&C: The hysteroscopy was inserted up to the top of the fundus. Both cornua were observed. The cavity was inspected and the findings are thickened tissue. The cavity was curetted in a clock wise manner. After thorough curetting the gritty sensation was felt through out. The Path report came back with retained POC. I know 58558 won't fit with diagnosis code of retained POC.
I have read the email from Melanie where she advised someone in a somewhat similar case to use 59812 and 58555 if it was an incomplete SAB. Is that what I will use even though that was unknown at the time of surgery and that a suction D&C was not performed?

Thank you,

Cathy Satkus, CPC
Harvard Family Physicians


  • edited May 2017
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    Hi Cathy-
    I do not think draining an ovarian cyst meets the criteria of 58662. For
    that procedure I would use the unlisted code 58679.

    For the hysteroscopy procedure I would go with Melanie's suggestion
    although I feel it is a bit of overkill to report 58555 and 59812 as 59812 just
    states completed surgically and does not specify a specific method.


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