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Posted and filed under YouBeTheCoder.

38 year old Female presented to the office for scheduled Essure sterilization. Patient identified, local anesthesia administered and the patient was placed in dorsal recumbent position. The physician uses a speculum to open the cervix and then places the hysteroscope to carry the coils into the fallopian tubes. Multiple attempts were taken to place the coils into the fallopian tubes, but due to blockage the coils were not able to be placed on the left and not securely placed on the right.

Due to these circumstances the physician elected to stop the procedure. It is recommended that the patient have a dye injection to assess the status of the fallopian tubes and determine the degree of blockage. Patient tolerated the procedure well and left in stable condition.

Question: What is the code for the procedure and what modifier should be appended to it?

See answer below


Answer: 58565-53

CPT 58565
Hysteroscopy; surgical with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants.

Modifier 53: Discontinued procedure
Under certain circumstances, the physician or other health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that the procedure was started but discontinued.