Monday, May 6, 2024

Coding Transcervical Uterine Ablation

This “Spotlight on CPT” blog will focus on uterine fibroid ablation.  With the January 1, 2024 CPT code update, a new code was implemented for transcervical ablation of uterine fibroids.   Previously, this was reported as a Category III code which was deleted this year and replaced with the code below.

58580   Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency

Let’s take a look at how this procedure is performed. The following pictures are of the Sonata procedure. In the first picture, you can see the handpiece is inserted via a transvaginal approach and then through the cervical opening and into the uterus.

 
 
The second picture demonstrates how the ultrasound waves are used to locate the fibroid(s) within the uterus.
 

 
 
The last picture shows how radiofrequency energy is used to shrink or ablate the fibroid.
 
 
When a uterine fibroid ablation is performed laparoscopically, CPT code 58674 should be assigned instead of 58580. Additionally, if endometrial ablation is done by thermal or cyroablation, code 58580 would be incorrect. Separate codes exist for ablations performed by different methods.

Now, light has been shed on coding transcervical uterine ablation.


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About the Author 


Dianna Foley, RHIA, CHPS, CCS, CDIP, is an HIM professional with over 25 years of experience.  She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA, along with being an AHIMA-approved ICD-10-CM/PCS trainer.  Dianna has held many positions in HIM and is now an independent coding consultant.  She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna is an AHIMA-published author and has volunteered with AHIMA on projects including certification item writing, certification exam development, coding rapid design, and most recently has served on AHIMA’s nominating committee.  She is a presenter on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.