UPDATE: MINIMALLY INVASIVE SURGERY
When a problematic cervix or distorted anatomy makes it impossible to enter the uterus for hysteroscopy or other office procedures, a few good tools and techniques can help.
IN THIS ARTICLE
Traditional dilators. Tapered metal or plastic dilators facilitate access to a tightly stenotic external os (FIGURE 3). These instruments have a more symmetrical segment proximal to the tip to allow gentle, gradual dilation of the canal. However, when dilation is needed for the entire length of the cervix, as it frequently is in nulliparous women, the tapered end will not dilate the internal os unless it is passed far enough into the canal—but passing the instrument too far increases the risk of uterine perforation. In this scenario, a symmetric dilator may be a better option to achieve uniform diameter of the endocervical canal from external to internal os. Be cautious: These symmetric dilators sometimes require additional force.
When the entire length of the cervix needs to be dilated, it may be wise to use a symmetric dilator that is the same size as the tapered dilator before increasing the diameter, to reduce the risk of perforation.
FIGURE 2 A borrowed tool to unlock the external os
From the world of ophthalmology, a lacrimal-duct dilator facilitates dilation of the extremely stenotic cervix.
FIGURE 3 Tapered instruments allow gradual dilation
Tapered cervical dilators, like this disposable set, have a more symmetrical segment proximal to the tip.
When every dilator is too large
Occasionally, the external os is so completely closed that even a lacrimal-duct dilator cannot be placed. In this situation, administer 2 cc of local anesthetic in the region of the external os, then gently penetrate the os using the tip of a #11 scalpel blade. This technique generally allows quick and easy access to the endocervical canal. (Typically, the entire canal will not be stenotic and, once the external opening is created, easy dilation can be accomplished.)
Navigating a crooked cervical canal
When the cervical canal is distorted, sometimes even the most carefully selected dilator will fail.
Why?
Because the diameter of the cervix is not the obstacle.
When a straight—or even partially curved—dilator cannot traverse the tortuous path of a distorted canal, the small flexible hysteroscope may offer a solution, allowing identification of the anatomic obstruction and visualization of the course of the cervical canal. Prior visualization of the canal enhances proprioception with the dilating instrument and improves the likelihood of safe uterine access.
The use of concomitant ultrasonography may also be helpful.11
From the standpoint of a payer, obtaining surgical access to the site of a procedure is included in the procedure payment. This is generally the rule for surgical access on the day of the procedure. Some payers reimburse separately, however, when access (specifically, dilation of the cervix) is performed a day, or few days, before the procedure because of an anatomic problem—such as the cervical stenosis discussed in the main “Update” article.
What are your options?
You have several coding options available for dilation of the cervix, depending on the approach you take:
- When you’ve given oral misoprostol, bill the visit at which you prescribed the drug.
- When you’ve inserted misoprostol vaginally, report code 59200 [insertion of cervical dilator (e.g., laminaria, prostaglandin) (separate procedure)].
The fact that 59200 is found in the “Maternity Care and Delivery” chapter of the CPT does not limit its use to obstetric cases. Because this code has a zero-day global period, you are not considered to be in the postoperative period of the first procedure when the surgical procedure is performed the next day (or even longer afterward), and the two procedures will not be bundled.
Another method of cervical dilation is represented by code 57800 [Dilation of cervical canal, instrumental (separate procedure)], which also has a zero-day global period.
The diagnosis code must support the service
That’s true whichever technique you choose. In this case, the diagnosis code will be either:
- 622.4 (Stricture and stenosis of cervix) or
- 752.49 (Other anomalies of cervix, vagina, and external female genitalia)—when the stenosis is the result of a congenital condition.—
MELANIE WITT, RN, CPC, COBGC, MA
