STOP Performing Dilation and Curettage for the Evaluation Of

STOP/START Diagnostic hysteroscopy spies polyp previously missed on transvaginal ultrasound and dilation and curettage. STOP performing dilation and curettage for the evaluation of abnormal uterine bleeding START performing in-office hysteroscopy to identify the etiology of abnormal uterine bleeding }expert commentary her treatment she had a 3-year history of Amy Garcia mD, Director, Center for abnormal vaginal bleeding. Results from con- Women’s Surgery and Garcia Institute for management secutive pelvic ultrasounds indicated that the Hysteroscopic Training, Albuquerque, and Clinical Assistant Professor, Department patient had progressively thickening endome- obg r of Obstetrics and Gynecology, University trium (from 1.4 cm to 2.5 cm to 4.7 cm). In-office O r f of New Mexico School of Medicine, Albu- E biopsy was negative for endometrial pathology. f querque. Dr. Garcia serves on the OBG ie An ultimate dilation and curettage (D&C) was K ManageMent Board of Editors. On the Web aig Dr. Garcia reports receiving grant support from Hologic; CASe In-office hysteroscopy spies being a consultant to Conceptus, Boston Scientific, Ethicon : Cr 12 intraoperative Endosurgery, IOGYN, Minerva, Hologic, Smith & Nephew, previously missed polyp ation videos from and Karl Storz Endoscopy; and being a member of the r A 51-year-old woman with a history of breast Dr. Garcia, at speakers’ bureau for Conceptus, Karl Storz Endoscopy, and ust ll obgmanagement.com cancer completed 5 years of tamoxifen. During Ethicon Endosurgery. I 44 OBG Management | June 2013 | Vol. 25 No. 6 obgmanagement.com performed with negative histologic diagnosis. FIGURE consecutive ultrasounds evaluating The patient is seen in consultation, and abnormal bleeding the ultrasound images are reviewed (FIGURE). These images show an increasing thickness of the endometrium with definitive intracavitary pathology that was missed with the previous clinical evaluation with endometrial biopsy and D&C. An in-office hysteroscopy is performed, and a large 5 x 4 x 7 cm cystic and fibrous polyp is identified with normal endometrium( VIDEO 1). a b abnormal uterine bleeding The evaluation of abnormal uterine bleeding (AUB), as described in this clinical scenario, is quite common. As a consequence, many patients have a missed or inaccurate diagnosis and undergo unnecessary invasive procedures under general anesthesia. AUB is one of the primary indications for a gynecologic consultation, accounting for c D approximately 33% of all gynecology visits, and for 69% of visits among postmenopausal Transvaginal ultrasounds showing increasing thickness of the endometrium. women.1 Confirming the etiology and plan- (A) Endometrium long axis, 2010. (B) Endometrium long axis, 2011. ning appropriate intervention is important (C) Endometrium long axis, 2012. (D) Endometrium transverse axis, 2012. in the clinical management of AUB because accurate diagnosis may result in avoiding major gynecologic surgery in favor of mini- 2001 that examined TVUS versus SH and DH mally invasive hysteroscopic management. for the investigation of AUB in premeno- pausal women. The researchers found that TVUS had a higher rate of false negatives for Diagnostic hysteroscopy is detecting intrauterine pathology, compared proven in aUb evaluation with SH and DH. They also found that DH Drawbacks of other diagnostic tools. It is was superior to SH in diagnosing submu- generally accepted that the initial evaluation cous myomas.2 of women with AUB is performed with non- In 2010, results of a prospective com- invasive transvaginal ultrasound (TVUS).1-3 As parison of TVUS, SH, and DH for detecting illustrated by the opening case, however, the endometrial pathology, showed that DH had accuracy of TVUS is limited in the diagnosis of a significantly better diagnostic performance focal endometrial lesions, and further investi- than SH and TVUS and that hysteroscopy was gation of the uterine cavity is warranted. significantly more precise in the diagnosis of Evaluation of the uterine cavity with intracavitary masses.3 sonohysterography (SH)—vaginal ultrasound Again, in 2012, a prospective compari- with the instillation of saline into the uterine son of TVUS, SH, and DH in the diagnosis cavity—is more accurate than TVUS alone. of AUB revealed that hysteroscopy provided FIGo classification Yet, diagnostic hysteroscopy (DH) has proven the most accurate diagnosis.1 system for identifying to be superior to either modality for the accu- In a systematic review and meta-analy- the cause of abnormal 1-3 rate evaluation of intracavitary pathology. sis, van Dongen found the accuracy of DH to uterine bleeding, evidence of DH superiority. Farquhar and be estimated at 96.9%.4 on page 48 colleagues reported results of a systematic Hysteroscopy is also considered to be 2 review of studies published from 1980 to July more comfortable for patients than SH. ContinueD on pAge 46 obgmanagement.com Vol. 25 No. 6 | June 2013 | OBG Management 45 STOP/START ContinueD fRom pAge 45 blinded sampling missed intracavitary lesions Visual comparison of current such as polyps and myomas that accounted for modalities for evaluation of the bleeding abnormalities.5 endometrial cavity The limitations of D&C are evident in the opening case, as the D&C performed in the transvaginal ultrasound image showing operating room under general anesthesia, endometrial polyp without visualization of the uterine cavity, failed to identify the patient’s intrauterine pathology. D&c is seldom necessary to evaluate aUb and has significant surgical risks beyond general anesthesia, includ- ing cervical or uterine trauma that can occur with cervical dilation and instrumentation of the uterus. As with D&C, endometrial biopsy has Sonohysterography video showing limitations in diagnosing abnormalities endometrial polyp within the uterine cavity. In a 2008 prospective comparative study of hysteroscopy versus blind biopsy with a suction biopsy curette, Angioni and colleagues showed a significant difference in the capability of these two procedures to accurately diagnose the etiology of bleeding for menopausal women. Blinded biopsy had a sensitivity for diagnosing polyps, myomas, and hyperpla- Hysteroscopy video showing endometrial polyp sia of 11%, 13%, and 25%, respectively. The D&c has a lower sensitivity of hysteroscopy to diagnose the sensitivity for same intracavitary pathology was 89%, 100%, 6 diagnosing the and 74%, respectively. etiology of aUb This does not mean, however, that the and has risks endometrial biopsy is not beneficial in the associated with evaluation of AUB. Several authors recom- mend that in a clinically relevant situation, general anesthesia endometrial biopsy with a small suction use curette should be performed concomitantly with hysteroscopy to improve the sensitivity of the overall evaluation with histology.7,8 And, as Loffer showed, the hysteroscopic evaluation with a visually directed biopsy is a procedure performed “blind” extremely accurate (VIDEOS 2, 3).5 limits its usefulness in aUb evaluation the bottom line for D&c use in aUb this statement is not a new realization. As evaluation far back as 1989, Loffer showed that blind D&C Sometimes a D&C is needed. For instance, was less accurate for diagnosing AUB than was when more tissue is needed for histologic hysteroscopy with visually directed biopsy. The evaluation than can be obtained with small sensitivity of diagnosing the etiology of AUB suction curette at endometrial biopsy. How- with D&C was 65%, compared to a sensitivity ever, there are several shortcomings of of 98% with hysteroscopy with directed biopsy. D&c for the evaluation of aUb: Hysteroscopy was shown to be better because • Most clinicians perform D&C in the 46 OBG Management | June 2013 | Vol. 25 No. 6 obgmanagement.com coding for in-office hysteroscopy Some procedures now can be performed in the office is considered integral to the procedure. Under CPT setting. Among these is operative hysteroscopy, for rules, you may bill separately for regional anesthesia. things such as abnormal uterine bleeding (AUB), foreign When performing office hysteroscopy, the most common body removal, and tubal occlusion. When performing regional anesthesia would be a paracervical nerve hysteroscopic evaluation of AUB, the Current Procedural block (CPT code 66435—Injection, anesthetic agent; Terminology (CPT) code 58558 (Hysteroscopy, paracervical [uterine] nerve). Under CPT rules, coding surgical; with sampling (biopsy) of endometrium and/or should go in as 58558-47, 64435-51. The modifier -47 polypectomy, with or without D&C) should be reported. lets the payer know that the physician performed the This code is reported whether polyp(s) are removed or a regional block, and the modifier -51 identifies the regional sampling of the uterine lining or a full D&C is performed. block as a multiple procedure. Under the resource-Based relative Value Medicare, however, will never reimburse separately System (rBrVS), used by the majority of payers for for regional anesthesia performed by the operating reimbursement, there is a payment differential for site physician, and because of this, Medicare’s Correct of service. In other words, when performed in the Coding Initiative (CCI) permanently bundles 64435 when office setting, reimbursement will be higher than in billed with 58558. Medicare will not permit a modifier the hospital setting to offset the increased practice to be used to bypass this bundling edit, and separate expenses incurred. In the office setting, 58558 has

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