The patient is a 35-year-old female who has been having prolonged and heavy bleeding during menstruation. After other testing, the patient opted to have an elective uterine ablation using NovaSure.
Procedure: After the patient was put under general anesthesia, the patient was placed in the dorsolithotomy position, after which the perineum and the vagina were prepped, the bladder was straight catheterized, and the patient was draped. After a bimanual exam was performed, a speculum was placed and the cavity integrity assessment performed. The NovaSure system uses a small amount of CO2 to verify cavity integrity prior to performing the procedure. The NovaSure thermal endometrial ablation procedure then delivered radiofrequency energy until tissue impedance reached 50 ohms; the electrode array was retracted for easy removal, leaving the uterine lining desiccated down to the superficial myometrium. The patient was awakened from anesthesia and sent home to recover.
Select the appropriate CPT and ICD-10-CM codes:

Question

Quizplus · Accepted Answer

The correct CPT code for the NovaSure thermal endometrial ablation procedure is 58353, as it specifically refers to endometrial ablation without hysteroscopic guidance, which matches the description of the NovaSure procedure. The correct ICD-10-CM code is N92.0, which is used for excessive and frequent menstruation with regular cycle, aligning with the patient's symptoms of prolonged and heavy bleeding.

The Patient Is a 35-Year-Old Female Who Has Been Having