How To Use CPT Code 58555

CPT 58555 is a diagnostic hysteroscopy procedure code, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 58555?

CPT 58555 is a diagnostic hysteroscopy procedure code used by medical professionals to report the examination of the uterine cavity using a hysteroscope. This code is specifically for diagnostic purposes and is billed when the provider performs a hysteroscopy to diagnose any abnormalities or issues within the uterus.

2. 58555 CPT code description

The official description of CPT code 58555 is: “Hysteroscopy, diagnostic (separate procedure)”.

3. Procedure

1. The patient is placed in the dorsal lithotomy position and administered a local or regional anesthetic.
2. The provider performs a bimanual pelvic exam to assess the size, position, and movement of the uterus.
3. A Foley catheter is inserted to drain the bladder.
4. The provider places a speculum into the vagina and dilates the cervix if needed to insert the hysteroscope into the uterus.
5. A uterine sound is used to determine the depth of the uterus before inserting the hysteroscope.
6. The hysteroscope is inserted, and the speculum is removed.
7. The uterine cavity is distended by introducing air or fluid.
8. While taking videos with the hysteroscope in place, the provider examines the entire uterine cavity and the endocervical canal.
9. Once the examination is complete, the hysteroscope is removed from the uterus, and the cervix is checked for bleeding from a possible puncture or laceration.
10. If bleeding is identified, it is controlled using sutures, pressure, or cautery, and all instruments are removed from the vagina and cervix.

4. Qualifying circumstances

Patients eligible to receive CPT code 58555 services are those who present with symptoms or conditions that warrant a diagnostic hysteroscopy. These may include abnormal uterine bleeding, infertility, recurrent miscarriages, suspected intrauterine adhesions, or the presence of polyps or fibroids. The procedure may also be performed to evaluate the uterine cavity before certain surgical procedures or to assess the results of previous treatments.

5. When to use CPT code 58555

It is appropriate to bill the 58555 CPT code when a diagnostic hysteroscopy is performed as a separate procedure to evaluate the uterine cavity for any abnormalities or issues. This code should not be used when the hysteroscopy is performed in conjunction with another surgical procedure, as the diagnostic component may be included in the primary procedure’s code.

6. Documentation requirements

To support a claim for CPT 58555, the medical record should include the following information:

• Indication for the diagnostic hysteroscopy (e.g., abnormal uterine bleeding, infertility, etc.)
• Details of the patient’s medical history and physical examination
• Findings of the bimanual pelvic exam
• Details of the hysteroscopy procedure, including anesthesia, instruments used, and any complications encountered
• Findings of the hysteroscopy, including any abnormalities or issues identified within the uterine cavity and endocervical canal
• Any interventions performed to address bleeding or other complications

7. Billing guidelines

When billing for CPT code 58555, it is essential to follow the appropriate guidelines and rules. Some tips and codes that apply to CPT code 58555 include:

• Ensure that the hysteroscopy is performed as a separate diagnostic procedure and not in conjunction with another surgical procedure.
• Document the medical necessity for the diagnostic hysteroscopy in the patient’s medical record.
• Verify that the patient meets the qualifying circumstances for CPT code 58555.
• Include all required documentation to support the claim for CPT 58555.

8. Historical information

CPT 58555 was added to the Current Procedural Terminology system on January 1, 2000. There have been no updates to the code since its addition.

9. Similar codes to CPT 58555

Five similar codes to CPT 58555 and how they differentiate from CPT 58555 are:

1. CPT 58558: This code is for a hysteroscopy with biopsy, which includes the removal of tissue for examination.
2. CPT 58559: This code is for a hysteroscopy with lysis of intrauterine adhesions, which involves the removal of scar tissue within the uterus.
3. CPT 58560: This code is for a hysteroscopy with division or resection of the septum, which involves the removal of a uterine septum.
4. CPT 58561: This code is for a hysteroscopy with removal of leiomyomata, which involves the removal of uterine fibroids.
5. CPT 58562: This code is for a hysteroscopy with removal of a foreign body, which involves the removal of an object from the uterus.

10. Examples

Here are 10 detailed examples of CPT code 58555 procedures:

1. A patient with abnormal uterine bleeding undergoes a diagnostic hysteroscopy to evaluate the cause of the bleeding.
2. A patient with a history of infertility undergoes a diagnostic hysteroscopy to assess the uterine cavity for any abnormalities that may be contributing to the infertility.
3. A patient with recurrent miscarriages undergoes a diagnostic hysteroscopy to evaluate the uterine cavity for any issues that may be causing the miscarriages.
4. A patient with suspected intrauterine adhesions undergoes a diagnostic hysteroscopy to confirm the presence of adhesions and assess their extent.
5. A patient with a known uterine polyp undergoes a diagnostic hysteroscopy to evaluate the size and location of the polyp.
6. A patient with a history of uterine fibroids undergoes a diagnostic hysteroscopy to assess the current state of the fibroids and determine if further treatment is necessary.
7. A patient scheduled for a surgical procedure involving the uterus undergoes a diagnostic hysteroscopy to evaluate the uterine cavity before surgery.
8. A patient who has undergone treatment for uterine abnormalities undergoes a diagnostic hysteroscopy to assess the results of the treatment.
9. A patient with persistent pelvic pain undergoes a diagnostic hysteroscopy to evaluate the uterine cavity for any abnormalities that may be causing the pain.
10. A patient with a history of endometrial hyperplasia undergoes a diagnostic hysteroscopy to assess the current state of the endometrium and determine if further treatment is necessary.