cpt 58340, cpt code 58340, 58340 cpt code

How To Use CPT Code 58340

CPT 58340 is a procedure code for catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 58340 procedures.

1. What is CPT 58340?

CPT 58340 is a medical procedure code used to describe the catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography. This procedure is performed to examine the uterus and fallopian tubes for blockage or abnormalities by using ultrasound or X-ray imaging.

2. 58340 CPT code description

The official description of CPT code 58340 is: “Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography.”

3. Procedure

The CPT 58340 procedure involves the following steps:

  1. The patient is placed in a dorsal lithotomy position, and a speculum is inserted into the patient’s vagina.
  2. For sonohysterography (SIS), a flexible catheter is inserted through the cervix into the cavity of the uterus.
  3. Saline is instilled into the uterus through the catheter, and a separately reportable ultrasound is used to detect any abnormal growth inside the uterus.
  4. For hysterosalpingography (HSG), a dye is injected into the uterus, which spreads to the fallopian tubes, allowing the provider to observe the tubes by X-ray examination and check for abnormalities or blockage.
  5. When the procedure is complete, the catheter and speculum are removed.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 58340 services are those experiencing symptoms or conditions that warrant an examination of the uterus and fallopian tubes. These may include infertility, abnormal uterine bleeding, pelvic pain, or a history of pelvic inflammatory disease. The procedure may also be performed as part of a diagnostic workup for suspected uterine or fallopian tube abnormalities.

5. When to use CPT code 58340

It is appropriate to bill the 58340 CPT code when the provider performs catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography to examine the uterus and fallopian tubes for blockage or abnormalities. The code should be used in conjunction with other relevant codes, such as 76831 for SIS or 74740 for HSG, depending on the specific imaging technique used during the procedure.

6. Documentation requirements

To support a claim for CPT 58340, the following information should be documented:

  • Patient’s medical history and presenting symptoms or conditions that warrant the procedure
  • Physical examination findings
  • Details of the procedure, including the type of imaging used (SIS or HSG), the type of contrast material or saline used, and any complications encountered
  • Findings from the ultrasound or X-ray examination, including any abnormalities or blockages detected
  • Provider’s interpretation of the imaging results and any recommendations for further evaluation or treatment

7. Billing guidelines

When billing for CPT code 58340, it is important to follow the appropriate guidelines and rules. If the provider performs an ultrasound to view the inside of the uterus after saline injection, report 76831 for saline infusion sonohysterography, including color flow Doppler, when performed. Do not code a transvaginal ultrasound, 76830, in addition, because 76831 represents the entire ultrasound examination.

If the provider injects contrast material instead of saline and performs the interpretation of the X-ray, report 74740 for hysterosalpingography, radiological supervision, and interpretation, in addition to 58340. If both saline and contrast material are injected into the uterine cavity, but only the uterus is evaluated using ultrasound, code the service as 58340 and 76831.

8. Historical information

CPT 58340 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2004, with the previous descriptor being “Catheterization and introduction of saline or contrast material for hysterosonography or hysterosalpingography.”

9. Similar codes to CPT 58340

Five similar codes to CPT 58340 and how they differentiate from CPT 58340 are:

  1. CPT 58345: This code is used for transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency, which is a different procedure from CPT 58340.
  2. CPT 76830: This code is for a transvaginal ultrasound examination, which is a separate imaging procedure and not the same as CPT 58340.
  3. CPT 76831: This code is for saline infusion sonohysterography, including color flow Doppler, when performed, and is used in conjunction with CPT 58340 when appropriate.
  4. CPT 74740: This code is for hysterosalpingography, radiological supervision, and interpretation, and is used in addition to CPT 58340 when the provider performs the interpretation of the X-ray.
  5. CPT 74742: This code is for fallopian tube recanalization, radiological supervision, and interpretation, which is a different procedure from CPT 58340.

10. Examples

Here are 10 detailed examples of CPT code 58340 procedures:

  1. A 35-year-old woman with a history of infertility undergoes a hysterosalpingography to evaluate her fallopian tubes for blockage.
  2. A 28-year-old woman with a history of pelvic inflammatory disease undergoes a saline infusion sonohysterography to assess her uterus for any abnormalities.
  3. A 40-year-old woman with abnormal uterine bleeding undergoes a saline infusion sonohysterography to evaluate the inside of her uterus.
  4. A 32-year-old woman with pelvic pain and suspected endometriosis undergoes a hysterosalpingography to evaluate her fallopian tubes and uterus.
  5. A 38-year-old woman with a history of recurrent miscarriages undergoes a saline infusion sonohysterography to assess her uterine cavity for any abnormalities.
  6. A 30-year-old woman with a suspected uterine fibroid undergoes a saline infusion sonohysterography to confirm the diagnosis and assess the size and location of the fibroid.
  7. A 33-year-old woman with a history of ectopic pregnancy undergoes a hysterosalpingography to evaluate her fallopian tubes for any blockage or abnormalities.
  8. A 36-year-old woman with unexplained infertility undergoes a saline infusion sonohysterography to assess her uterine cavity for any abnormalities that may be contributing to her infertility.
  9. A 29-year-old woman with a suspected uterine polyp undergoes a saline infusion sonohysterography to confirm the diagnosis and assess the size and location of the polyp.
  10. A 42-year-old woman with a history of tubal ligation undergoes a hysterosalpingography to evaluate her fallopian tubes for any blockage or abnormalities.

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