Health Information Management

Tip: Don't bill these bundled procedures with hysteroscopic procedures

APCs Insider, July 29, 2011

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When using a hysteroscope, physicians inflate the uterus with gas or fluid to obtain a better view of the entire uterine cavity. In the operative or procedure record, this gas or fluid is commonly referred to as the distending medium.

The following procedures are always included or bundled with hysteroscopic procedures; do not code them separately:

  • Examination under anesthesia, which includes ¬visualization of the vagina and cervix
  • Bladder catheterization
  • Application of a tenaculum and dilation of the cervix or cervical canal
  • Insertion of a hysteroscope and distending media such as gas or fluid
  • Inspection of the uterine cavity
  • Injection or placement of local anesthesia, conscious sedation, or application of a nerve block used for anesthesia
  • Removal of instruments, catheters, or drains
  • Photo and operative report documentation


The tip is adapted from “Review documentation for correct hysteroscopy coding” in the June issue of Briefings on APCs.



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