Endometrial Ablation (CPB 0091, reviewed 2026-03-25)

By 2026-03-25: Billing team must immediately implement the following workflow changes: (1) Update billing system to require documentation of prior D&C or hormonal therapy failure before approving CPT 58353, 58356, or 58563 claims; (2) Implement automated denial logic for CPT 76376-76377 when billed for 3D pelvic ultrasound related to endometrial ablation measurement; (3) Add system rules to deny HCPCS J7297 and J7298 when billed on the same claim as endometrial ablation codes; (4) Create pre-billing checklist for endometrial ablation cases requiring verification of: endometrial sampling/D&C within past year, current Pap smear results, exclusion of fibroids/polyps by ultrasound, and medical necessity documentation; (5) Add ICD-10 code validation to reject N95.0 (postmenopausal bleeding) claims for ablation procedures; (6) Flag CPT 58565 (hysteroscopic sterilization with ablation) for manual review and potential denial, as ablation reduces sterilization success; (7) Ensure providers document all selection criteria on encounter forms before submission. Providers must include historical treatment failure documentation and current screening results. Front desk and authorization staff should request medical records confirming prior conservative therapy attempts. Claims lacking required documentation will be denied.