AHA Coding Clinic® for HCPCS - 2024 Issue 2; Clarification

Clarification: Endometrial ablation with hysteroscopic guidance

A patient presented to a hospital outpatient department for hysteroscopy, IUD removal, endometrial ablation and dilation and curettage (D&C). Under general anesthesia, a weighted speculum was placed in the posterior fornix. Following a paracervical block, the cervix was dilated in order to insert a diagnostic hysteroscope. The hysteroscope was inserted, advanced, and the cavity length was determined. The IUD was grasped and removed intact without difficulty or fragmentation. Both tubal ostia were identified; a proliferative endometrium and normal endocervix were noted. The hysteroscope was then removed. Curettage was performed and a moderate amount of tissue was obtained. Then, the intrauterine ablative device was inserted and deployed completing an entire cycle. The Co2 test indicated no perforation. Following removal of the intrauterine ablative device, a repeat hysteroscopy was carried out, noting excellent desiccation. All instruments were removed, and hemostasis was obtained. Coding Clinic for HCPCS Third Quarter 2006, question 7, indicated code assignment was based on whether or not hysteroscopic guidance was utilized. We are unsure what “guidance” means. Must the hysteroscope be used at the same time as the ablation to “guide” the ablative device in order to assign CPT code 58563? What is the correct coding for this endometrial ablation when the hysteroscope is utilized, but not simultaneously with the ablation? ...

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