Frequently Asked Questions
1. What is the appropriate code to report when
5. What procedures are included in CPT 58356
performing endometrial cryoablation utilizing
and not separately billable?
the Her Option® therapy system?
Below are some of the more commonly performed
(Endometrial cryoablation with ultrasonic guid-
procedures which are not separately billable according
ance, including endometrial curettage, when performed)
to National Correct Coding Initiative (NCCI) edits. (Not
is the appropriate CPT code to report when utilizing the
all commercial payers follow NCCI edit guidelines.)
• 58100 — Endometrial sampling (biopsy) with or
2. Is prior authorization or pre-certification
without endocervical sampling (biopsy), without
necessary for the endometrial cryoablation
cervical dilation, any method (separate procedure)
• 58120 — Dilation and curettage, diagnostic and/or
As a rule, Medicare does not require prior authorization for any procedure. Commercial or private insurance car-
•● 58340 — Catheterization and introduction of saline
riers (e.g., Aetna, Blue Cross, etc.) and some Medicare
or contrast material for infusion sonohysterography
supplemental plans may require a prior authorization or
pre-certification for surgical procedures. Therefore, it is
•● 64435 — Injection, anesthetic agent; paracervical
recommended that you check with insurers (primary and
secondary) to verify coverage and pre-certification require-ments prior to performing any procedure.
6. Is CPT 58356 payable in an Ambulatory Surgery
3. What modifier is used to report CPT® 58356
in the office setting to receive the global
Commercial payers will vary in coverage and payment based upon individual contractual agreements with the
ASC. Check with each payer for individual guidelines.
CPT 58356 does not require the use of a modifier. The site of service entered on the claim showing that the procedure
As it applies to Medicare patients, procedures not listed on
was performed in the office should trigger the global rate.
the Medicare Approved ASC list may be performed in the ASC. The ASC is prohibited from billing Medicare or the
4. What HCPCS codes for drugs might be used in
patient. Because of this, the payment will be to the
conjunction with CPT 58356?
physician only and will be at the non-facility (office) rate (http://www.cms.hhs.gov/manuals/downloads/clm104c12
Some common pre- or post-procedure injectables and
.pdf). Due to the unique nature of reimbursement for these
their associated HCPCS codes are as follows:
procedures, it is recommended that a written agreement between the physician and the facility be in place before
• J2001 — Injection, lidocaine HCl for intravenous
the procedure is performed. FASA (www.fasa.org) recom-
mends that the ASC “should seek to at least recover its
• S0020 — Injection, bupivacaine HCl 30 ml
cost from physicians who use the facility for non-ASC
(use this code for Marcaine, Sensorcaine)
procedures.” It is recommended that the facility also checks with their malpractice insurer to ascertain whether
•● J1885 — Injection, ketorolac tromethamine,
or not performing such procedures voids coverage.
•● J9218 — Leuprolide acetate, per 1 mg
continued on reverse
Frequently Asked Questions
7. Is it appropriate for a physician to bill for a
8. How much do Medicare and commercial payers
diagnostic hysteroscopy when performed prior
pay for endometrial cryoablation procedures?
to an ablation procedure?
The Centers for Medicare and Medicaid Services (CMS)
When both procedures are done in the same surgical set-
publishes the Medicare payment rates for physicians,
ting but as distinct procedures, it is appropriate to submit a
hospitals and ambulatory surgery centers. Payment
diagnostic hysteroscopy code, CPT 58555, with a 59 modi-
information may be accessed via the CMS website —
fier in addition to an ablation procedure code (e.g., 58353
http://www.hhs.gov and navigating to the appropriate
or 58356). The 59 modifier indicates that the diagnostic
portion of the case is a distinct procedure from the ablation because they use two methods.
Fee schedules for commercial payers are contract driven and considered proprietary information. Fee schedules
When reporting a surgical code with a 59 modifier, many
may be based on a percentage of Medicare, discounted
payers may require documentation to review the case in
charges, capitation or some other method. If a provider
order to determine whether or not the modifier is justified.
has not contracted with a particular payer, reimbursement
In these cases, it is important for the provider to know and
is typically made at U & C (usual and customary) or billed
understand each payer’s specific requirements around
amount. Before performing any new procedures, contact
the use of the modifier. If documentation is needed, any
the individual payer to obtain the fee schedule amounts
electronically submitted claim may be line-item denied until
and any requirements pertaining to prior authorization or
the payer receives the physician’s notes. In this case, it is
better for the physician to send a paper claim with docu-mentation instead of submitting an electronic claim.
While reasonable efforts have been made to ensure the accuracy of the
information set forth, AMS, Inc. can not guarantee reimbursement for any product or
procedure. Providers should report the codes that accurately describe the products
and procedures furnished and the patient’s medical condition. Providers should
contact their payers if they have questions or need specific co-payment, coverage
and billing/coding policies as well as to update the information described herein.
January 2007 American Medical Systems, Inc.
1. CPT 2007. Current Procedural Terminology. Professional Edition. CPT is a
trademark of the American Medical Association, Chicago, IL
2. HCPCS Level II Expert, 2007. Healthcare Common Procedure Coding System.
American Medical Association. Ingenix, Inc. Salt Lake City, UT
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