CPT Code 58558: Hysteroscopy, Surgical; With Sampling (Biopsy) of Endometrium and/or Polypectomy, With or Without D&C
Read this guide to learn about CPT code 58558 for hysteroscopy (surgical) with biopsy and/or polypectomy, with or without dilation and curettage.
What is CPT 58558 code all about?
CPT code 58558 is one of the CPT codes related to hysteroscopy that you can use to report and bill for the procedure.
Hysteroscopy is a minimally invasive procedure. A hysteroscope (which is a small camera) will be inserted into the patient's uterus via their vagina and cervix by a doctor so they can observe the uterine lining and cavity.
Through this procedure, the doctor can view the uterine lining and cavity, perform biopsies, remove any present polyps (polypectomy), and, if needed, conduct D&C (dilation and curettage).
Doctors will observe the following:
- Abnormal uterine bleeding (including postmenopausal bleeding)
- Uterine polyps and fibroids
- Signs of infertility
- Thickening of the endometrial lining
As with any invasive procedure, minimal or otherwise, there are risks to this:
- Infections
- Bleeding
- Intrauterine adhesions and scarring
- Uterine perforation
- Allergic reactions to anesthesia, to name a few
Follow-ups might be needed to continue observation of the uterine cavity and determine if certain treatment is required, especially surgical ones like endometrial resection, endometrial ablation, electrosurgical ablation, and bilateral fallopian tube cannulation.
CPT code 58558 documentation requirements
Before filing for report and billing using this code, please make sure to document the following clearly:
- The medical necessity of hysteroscopy
- Any preoperative findings you have obtained
- Detailed operative report that includes endoscopic findings, polypectomy (if conducted), polyp sizes and locations (if polyps were found and removed), and the specific biopsy site
- The total duration of the procedure. This usually ranges from 30 minutes to an hour
- The type of anesthesia used must also be documented
- Any intraoperative complications must also be documented
- If you have a post-operative plan and scheduled follow-ups, those must be documented, too
CPT code 58558 billing guidelines
Besides clear documentation, here are things to note when reporting and billing using this CPT code:
- 58558 is only billed once, regardless of the number of polyps removed.
- Please note that you cannot bill this on the same day as the use of CPT code 58555 (diagnostic, hysteroscopy). However, it's best to review the guidelines of your specific insurance provider, just in case.
- You can't use this code alongside the biopsy of the uterus lining (CPT code 58100).
Commonly asked questions
58555 is used when a diagnostic hysteroscopy is conducted. 58562 is for hysteroscopy accompanied by the surgical removal of an impacted foreign body.
Gynecologists (including surgeons), anesthesiologists, and nurses.
They will likely have to rest for a week. They will likely experience cramping and spotting throughout the recovery period. They also have to avoid having sex, using tampons, and exercising (especially types that require heavy lifting or a lot of effort).
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