How To Use CPT Code 58561

CPT 58561 refers to a surgical hysteroscopy procedure involving the removal of leiomyomata, or fibroids, from the uterus. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT code 58561 procedures.

1. What is CPT 58561?

CPT 58561 is a medical procedure code used to describe a surgical hysteroscopy involving the removal of leiomyomata, or fibroids, from the uterus. This code is utilized by healthcare providers to accurately document and bill for this specific procedure.

2. 58561 CPT code description

The official description of CPT code 58561 is: “Hysteroscopy, surgical; with removal of leiomyomata.”

3. Procedure

  1. The patient is placed in the dorsal lithotomy position and administered a local or regional anesthetic.
  2. A bimanual pelvic exam is performed to determine the size, position, and movement of the uterus.
  3. A Foley catheter is inserted to drain the bladder.
  4. A speculum is inserted into the vagina, and the cervix is dilated as necessary for the insertion of the hysteroscope.
  5. A uterine sound is used to determine the depth of the uterus, and the hysteroscope is inserted.
  6. The speculum is removed, and the uterine cavity is distended with air or fluid.
  7. While taking videos with the hysteroscope in place, the provider examines the entire uterine cavity and the endocervical canal.
  8. The provider identifies the fibroids and resects each one of them to the level of the adjacent endometrium with scissors, wire loop electrode, or laser.
  9. Any bleeding points are coagulated, and hemostasis is obtained.
  10. The hysteroscope is removed from the uterus, and the cervix is checked for bleeding from a possible puncture or laceration. If bleeding is identified, it is controlled using sutures, pressure, or cautery.
  11. All instruments are removed from the vagina and cervix.

4. Qualifying circumstances

Patients eligible to receive CPT code 58561 services are those diagnosed with uterine fibroids, which are causing symptoms such as heavy menstrual bleeding, pelvic pain, or pressure on the bladder or bowel. The procedure is typically performed when conservative treatments, such as medication, have not provided adequate relief or when the fibroids are causing significant discomfort or complications.

5. When to use CPT code 58561

It is appropriate to bill the 58561 CPT code when a healthcare provider performs a surgical hysteroscopy with the removal of leiomyomata, or fibroids, from the uterus. This code should be used only when the procedure is performed for the specific purpose of removing fibroids and not for other types of uterine growths, such as polyps.

6. Documentation requirements

To support a claim for CPT 58561, the following information should be documented in the patient’s medical record:

  • Patient’s medical history and symptoms related to uterine fibroids
  • Diagnostic tests confirming the presence of fibroids
  • Conservative treatments attempted and their outcomes
  • Details of the surgical hysteroscopy procedure, including the size, location, and number of fibroids removed
  • Postoperative care instructions and follow-up appointments

7. Billing guidelines

When billing for CPT code 58561, it is essential to follow the specific guidelines and rules set forth by the payer. Some tips for billing this code include:

  • Ensure that the procedure is medically necessary and supported by the patient’s medical record.
  • Verify that the documentation accurately reflects the surgical hysteroscopy procedure and removal of fibroids.
  • Check for any additional codes that may apply, such as anesthesia or facility fees.
  • Review payer-specific guidelines for any additional requirements or restrictions.

8. Historical information

CPT 58561 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 58561

Five similar codes to CPT 58561 and how they differ are:

  • CPT 58555: This code is for diagnostic hysteroscopy, which does not involve the removal of fibroids.
  • CPT 58558: This code is for surgical hysteroscopy with sampling (biopsy) of endometrium and/or polypectomy, with or without dilation and curettage (D&C), which does not involve the removal of fibroids.
  • CPT 58562: This code is for surgical hysteroscopy with lysis of intrauterine adhesions, which does not involve the removal of fibroids.
  • CPT 58563: This code is for surgical hysteroscopy with endometrial ablation, which does not involve the removal of fibroids.
  • CPT 58565: This code is for surgical hysteroscopy with placement of intrauterine device (IUD), which does not involve the removal of fibroids.

10. Examples

Here are 10 detailed examples of CPT code 58561 procedures:

  1. A 35-year-old woman with heavy menstrual bleeding and pelvic pain undergoes a surgical hysteroscopy with removal of multiple fibroids.
  2. A 40-year-old woman with a history of infertility undergoes a surgical hysteroscopy with removal of a large submucosal fibroid.
  3. A 45-year-old woman with recurrent urinary tract infections and pressure on the bladder undergoes a surgical hysteroscopy with removal of multiple fibroids.
  4. A 38-year-old woman with severe pelvic pain and heavy menstrual bleeding undergoes a surgical hysteroscopy with removal of multiple fibroids using a wire loop electrode.
  5. A 42-year-old woman with a history of miscarriages undergoes a surgical hysteroscopy with removal of a large intramural fibroid.
  6. A 47-year-old woman with menorrhagia and anemia undergoes a surgical hysteroscopy with removal of multiple fibroids using a laser.
  7. A 36-year-old woman with dysmenorrhea and heavy menstrual bleeding undergoes a surgical hysteroscopy with removal of multiple fibroids using scissors.
  8. A 41-year-old woman with a history of pelvic inflammatory disease undergoes a surgical hysteroscopy with removal of multiple fibroids.
  9. A 39-year-old woman with a history of endometriosis undergoes a surgical hysteroscopy with removal of multiple fibroids.
  10. A 43-year-old woman with a history of uterine polyps undergoes a surgical hysteroscopy with removal of multiple fibroids.

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