How To Use CPT Code 58353

CPT 58353 describes the procedure of thermal endometrial ablation, which involves the removal of the lining of the uterus using a device that produces heat. Unlike hysteroscopic guidance, this procedure does not require the use of a hysteroscope. The purpose of this service is to stop or reduce excessive or abnormal uterine bleeding. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58353?

CPT 58353 is used to describe the procedure of thermal endometrial ablation, which involves the removal of the lining of the uterus using a device that produces heat. This procedure does not require the use of a hysteroscope for guidance. It is performed to stop or reduce excessive or abnormal uterine bleeding.

2. Official Description

The official description of CPT code 58353 is: ‘Endometrial ablation, thermal, without hysteroscopic guidance.’

3. Procedure

1. The provider places the patient in a dorsal lithotomy position and inserts a speculum into the vagina.
2. If necessary, the provider dilates the cervix to widen it.
3. A uterine sound is used to determine the depth of the uterus.
4. A balloon catheter is inserted into the vagina, through the cervix, and into the uterus.
5. The balloon is filled with fluid to expand and fill the entire uterine cavity.
6. The fluid is heated for approximately four minutes to destroy the uterine lining.
7. The balloon is left in the uterus for eight minutes to ensure complete destruction of the uterine lining.
8. The fluid is withdrawn and the balloon is removed from the uterus.

4. Qualifying circumstances

CPT 58353 is performed on patients who experience excessive or abnormal uterine bleeding. It does not require the use of a hysteroscope for guidance. The procedure may be performed using a balloon catheter, a triangular mesh electrode that uses radiofrequency energy, or other devices that produce heat, such as microwave energy or heated fluid.

5. When to use CPT code 58353

CPT code 58353 should be used when performing thermal endometrial ablation without hysteroscopic guidance. It is appropriate for patients with excessive or abnormal uterine bleeding who do not require the use of a hysteroscope during the procedure.

6. Documentation requirements

To support a claim for CPT 58353, the provider must document the following information:

• Patient’s diagnosis of excessive or abnormal uterine bleeding
• Procedure performed, including the use of thermal endometrial ablation without hysteroscopic guidance
• Date of the procedure
• Details of the procedure, such as the use of a balloon catheter or other devices that produce heat
• Any additional procedures performed, such as suction curettage
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 58353, ensure that the procedure is performed without hysteroscopic guidance. It is important to note that if a suction curettage is performed before the endometrial ablation, it is bundled and cannot be separately billed. Review the specific guidelines of the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 58353 was added to the Current Procedural Terminology system on January 1, 2001. There have been no updates to the code since its addition.

9. Examples

1. A patient with excessive uterine bleeding undergoes thermal endometrial ablation without hysteroscopic guidance to stop the bleeding.
2. A provider performs thermal endometrial ablation without hysteroscopic guidance on a patient with abnormal uterine bleeding.
3. A woman with excessive uterine bleeding undergoes thermal endometrial ablation without hysteroscopic guidance to reduce the bleeding.
4. A provider performs thermal endometrial ablation without hysteroscopic guidance on a patient with abnormal uterine bleeding to alleviate the symptoms.
5. A patient with excessive uterine bleeding undergoes thermal endometrial ablation without hysteroscopic guidance to manage the condition.
6. A provider performs thermal endometrial ablation without hysteroscopic guidance on a patient with abnormal uterine bleeding to improve their quality of life.
7. A woman with excessive uterine bleeding undergoes thermal endometrial ablation without hysteroscopic guidance to prevent further complications.
8. A provider performs thermal endometrial ablation without hysteroscopic guidance on a patient with abnormal uterine bleeding to restore normal menstrual function.
9. A patient with excessive uterine bleeding undergoes thermal endometrial ablation without hysteroscopic guidance to avoid the need for more invasive procedures.
10. A provider performs thermal endometrial ablation without hysteroscopic guidance on a patient with abnormal uterine bleeding to provide long-term relief.