Reporting Endometrial Ablation – A Treatment Procedure for Abnormal Uterine Bleeding

Endometrial ablation is a procedure that surgically destroys the lining of the uterus (endometrium). It is performed as part of treatment for abnormal uterine bleeding (AUB) occurring due to a non-cancerous condition. Reports suggest that up to 30 percent of women seek help from a physician for this condition during their lifetime. The procedure can be performed only on women who are not pregnant and do not plan to become pregnant in the near future. It is not recommended for women who have an active infection of the genital tract. This procedure is not a first-line treatment modality for controlling abnormal or heavy menstrual bleeding. It is typically considered only when several medical and hormonal therapies have not been sufficient to control the level of bleeding. Obstetrician-gynecologists or other specialists involved in performing endometrial ablation need to correctly understand the usage of the procedure codes. Experienced medical billing outsourcing companies with professional experience in this field can help physicians ensure billing and coding efficiency.

Why Is an Endometrial Ablation Performed?

A procedure designed to destroy the uterine lining (endometrium), endometrial ablation is generally recommended by physicians for women who experience extremely heavy menstrual periods that can’t be controlled with medications or an intrauterine device (IUD). The procedure is performed in the following cases –

• Unusually heavy periods (normally defined as soaking a pad or tampon every two hours or less)
• Bleeding that lasts longer than eight days or more
• Anemia from excessive blood loss

Even though in most cases the endometrial lining is destroyed, re-growth of the lining can occur in normal or abnormal ways. However, in younger women, tissue re-growth may occur months or years later.

Who Should Not Have Endometrial Ablation?

Endometrial ablation should not be done in women past menopause. It is not recommended for women with certain medical conditions, including the following –

• Disorders of the uterus or endometrium
• Endometrial hyperplasia
• Cancer of the uterus
• Recent pregnancy
• Current or recent infection of the uterus

Complications or risks associated with the procedure are rare. However, as all procedures have some amount of risk, physicians will review the chances of complications like pain, bleeding or infection, heat or cold damage to nearby organs and a puncture injury of the uterine wall from surgical instruments. As endometrial ablation isn’t a sterilization procedure, women need to continue using contraception. Pregnancy is not likely after ablation, but in certain cases, pregnancy can occur even after endometrial ablation. However, these pregnancies may cause higher risk to both the mother and the baby. It can result in miscarriage as the lining of the uterus gets damaged or else the pregnancy may occur in the fallopian tubes or cervix instead of the uterus. Women who undergo the procedure need to use birth control until after menopause. Sterilization may be a good option to prevent pregnancy after ablation.

Getting Prepared for the Endometrial Ablation Procedure

Prior to scheduling the procedure, the physician will perform a detailed medical evaluation including the type of medications taken by the patient, previous procedures undergone and any specific allergies to medications. They will discuss in detail all important aspects of the procedure – including the dos and don’ts – in the days and weeks leading up to the procedure. Standard pre-procedure protocols include –

• Taking a pregnancy test (as the procedure can’t be performed on pregnant women)
• Removing an IUD (as the procedure can’t be performed with an IUD in place)
• Getting tested for endometrial cancer – A thin tube (catheter) is inserted through the cervix to obtain a small sample of endometrium to be tested for cancer)
• Making the uterine lining thin – Uterine lining need to be thinned beforehand as this can make the procedure more effective. Physicians may prescribe medications or perform a dilation and curettage (D&C) to scrape out the extra tissue.
• Discuss anesthesia options – Not all endometrial ablation procedures require anesthesia. Certain types of endometrial ablation may be performed with conscious sedation or with numbing shots into the cervix and uterus.

In addition, a visual examination of the uterus will be performed using certain imaging tests like ultrasounds – to rule out polyps or benign tumors, which may be causing heavy menstruation.

Types of Endometrial Ablation – How Is it Performed?

Endometrial ablation is performed in a hospital setting under general anesthesia. As part of the procedure, the physician will initially insert a slender instrument through the cervix and into the uterus – which widens the cervical area thereby allowing the physicians to perform the procedure. The opening in the cervix needs to be widened (dilated) to allow for the passage of the instruments used in endometrial ablation. Dilation of cervix can happen with medication or the insertion of a series of rods that gradually increase in diameter.

Endometrial ablation procedures vary by the method used to remove or destroy the endometrium. The type of instrument a physician uses will depend on which procedure is being carried out. There are different types of endometrial ablation –

• Freezing (cryoablation) – In this technique, a thin probe with a cold tip is used to freeze and destroy the lining of the uterus. The physician may place an ultrasound monitor on the abdomen that helps them guide the probe. Each freeze cycle takes up to six minutes and the number of cycles required depends on the size and shape of the uterus.
• Hydrothermal – Performed in women with irregularly shaped uterine cavities (from abnormal tissue growth – such as intracavity lesions or uterine fibroids) the procedure involves heated saline liquid being pumped or circulated into the uterus for about 10 minutes – which destroys the uterine lining.
• Heated Balloon – A balloon – inflated and filled with hot fluid – is inserted into the uterus through a tube. As the balloon expands, the heat destroys the uterine lining. Depending on the type of balloon device, the procedure can take from 2 to 10 minutes.
• Radiofrequency – A flexible device with a mesh tip is placed into the uterus. The device transmits radiofrequency energy that vaporizes the endometrial tissue in one to two minutes. The device is then removed from the uterus.
• Electrosurgery – Performed under general anesthesia, the procedure utilizes a telescopic device called a resectoscope and a heated instrument is used to see and remove uterine tissue.
• Microwave – A slender probe that emits microwave energy is used to destroy the uterine lining. The procedure takes 3 to 5 minutes to complete.

The length of recovery will vary and depend on the type of procedure undergone. If the procedure involved a general anesthesia, the patient will have to stay in the hospital for several hours or for a day after undergoing the treatment. Soon after the procedure, patients may experience menstrual-type cramping for several days; watery, bloody vaginal discharge for several weeks; nausea and increased or frequent urination tendency during the first 24 hours after the procedure. Over-the-counter medications such as ibuprofen or acetaminophen can help relieve cramping. If the patient experiences additional symptoms like – foul-smelling discharge, trouble while urinating, heavy bleeding, extreme abdominal cramping and fever and chills – it is important to seek medical attention immediately to reduce the risk of infections and other complications.

Recovery after endometrial ablation may last anywhere from a few days to a few weeks. During this period, patients must make sure to treat themselves with care. It is important to discuss with the healthcare provider about when to resume daily activities, as well as more strenuous exercise and sexual intercourse.

Medical Codes to Report Endometrial Ablation

Physicians performing the procedure must use the relevant medical codes to bill for the procedure correctly. Outsourced medical billing and coding services can help physicians use the correct codes for their billing purposes. Related medical codes for endometrial ablation include –

CPT Codes

• 58300 Insertion of intrauterine device (IUD)
• 58301 Removal of intrauterine device (IUD)
• 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
• 58353 Endometrial ablation, thermal, without hysteroscopic guidance
• 58356 Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed
• 58555 Hysteroscopy, diagnostic (separate procedure)
• 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C
• 58561 Hysteroscopy, surgical; with removal of leiomyomata
• 58563 Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation)
• 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
• 58674 Laparoscopy, surgical, ablation of uterine fibroid(s) including intra-operative ultrasound guidance and monitoring, radiofrequency
• 57558 Dilation and curettage of cervical stump [covered when the results of the histo-pathological report from the endometrial sampling procedure have been reviewed before the ablation procedure is scheduled, and where structural abnormalities (fibroids, polyps) that require surgery or represent a contraindication to an ablation procedure have been excluded]
• 57800 Dilation of cervical canal, instrumental (separate procedure)
• 74740 Hysterosalpingography, radiological supervision and interpretation
• 76830 Ultrasound, transvaginal
• 76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed

HCPCS Codes

• C1886 Catheter, extravascular tissue ablation, any modality (insertable)

ICD-10 Codes

• N92 Excessive, frequent and irregular menstruation
  • N92.0 Excessive and frequent menstruation with regular cycle
  • N92.1 Excessive and frequent menstruation with irregular cycle
  • N92.2 Excessive menstruation at puberty
  • N92.3 Ovulation bleeding
  • N92.4 Excessive bleeding in the premenopausal period
  • N92.5 Other specified irregular menstruation
  • N92.6 Irregular menstruation, unspecified
• N95.0 Postmenopausal bleeding

Endometrial ablation works well to stop or reduce menstrual bleeding for women who experience heavy or long periods or bleeding in between periods. After the procedure, menstrual periods will reduce or stop completely within a few months. However, the procedure is not an option for all women. It is normally carried out as a last resort – if other methods, such as medication or an IUD, have not worked.

Obstetrics and gynecology medical billing and coding can be challenging. Physicians can rely on medical billing services to submit accurate claims. Reputable billing and coding companies provide the services of expert coders well-versed in the latest coding and billing guidelines.