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Hysteroscopy D&C CPT Code 58558 | Description & Billing Guide

Hysteroscopy D&C CPT code 58558 can be reported for the service when the physician performs surgery on the uterus aided by a scope (hysteroscopy). Below are the description and guidelines for CPT 58558.

Reasons For A Hysteroscopy D&C Procedure

The following are why the physician performs D&C with hysteroscopy CPT code 58558.

The hysteroscopy D&C procedure described by CPT 58558 can be used;

  • to treat and diagnose the causes of abnormal bleeding;
  • to remove abnormal growth such as non-cancerous growths in the uterus;
  • to determine and remove the adhesions, such as Asherman’s Syndrome (uterine adhesions are bands of scar tissue), which may cause modification in the menstrual cycle and infertility. 
  • identify the uterine septum or a malformation (defect) of the uterus that is present from birth.
  • determine the cause of heavy or lengthy menstrual flow and bleeding after menopause. Endometrial ablation may perform with a hysteroscope to eliminate the uterine lining and treat some causes of heavy bleeding.

Hysteroscopy D&C Procedure Explained

A Hysteroscopy D&C procedure (CPT 58558) starts with a physician performing a diagnostic inspection of the uterus, removing a uterine polyp, and removing uterine tissue for biopsy. The surgeon conduct cervical dilation and uterine curettage (D&C). 

The physician traverses the hysteroscope through the vagina and into the cervical os to enter the uterine cavity.

The physician examines the uterine cavity with the fiberoptic scope and eliminates a sample of the uterine lining.

Hysteroscopy D&C (CPT code 58558) includes uterine curettage and scraping (D&C) to thoroughly sample the uterine lining and the removal of growth (polypectomy) within the uterus and cervical dilation.

A D&C is a minimal surgical procedure to eliminate the tissue from the uterus and might perform in addition to CPT 58558. This surgery may serve in the gynecologist, obstetrician’s office, or ambulatory surgery center. The patient may discharge on the same day.

The physician dilates or opens the cervix, which is the opening of the uterus where it joins the top of the vagina. It dilates typically during childbirth.

CPT Code 58558 Description

CPT 58558 bills for the service when the physician performs hysteroscopy, surgical, sampling (biopsy) of the endometrium, and polypectomy, with or without D & C. 

CPT code 58558 for Hysteroscopy D&C is officially described in CPT’s manual as: “Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C.”

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Description of the CPT code 58558 for Hysteroscopy D&C

CPT 58558 is one of the eight codes used in hysteroscopy. The base code of each family is often included in subsequent family codes.

For example, a 58555 (diagnostic hysteroscopy) is incorporated in a 58558 (hysteroscopic polypectomy).

Every year, the National Correct Coding Initiative (NCCI) discloses the details of which codes may and cannot be reported together (NCCI or CCI edits).

Many of these surgeries need a paracervical block since the anesthetic delivered by the surgeon is not billable to CMS (64435).

Five codes are graded when hysteroscopy is performed in an office rather than an institution.

For procedures conducted in a facility, the additional RVUs cover the costs that otherwise would have been paid by a physician’s office.

For example, hysteroscopic codes include the cost of the scope, fluid management system, polyp-resecting disposable devices and tubing, fluids and drapes, and gloves.

They also cover costs such as nurse time and supplies and the cost of the bed in the room and the exam table lamp.

As a provider, you are responsible for the consenting, examination, and documentation on the day of the procedure; you are also responsible for talking with the patient and their family.

The hysteroscope is inserted into the vaginal canal and the cervix via the cervix’s opening.

The treatment with laparoscopy may help identify or treat a problem to reach the uterine chamber, and abnormal uterine bleeding is a common reason for diagnosis.

CPT Code 58558 Billing Guidelines

Documentation must establish the medical necessity and appropriateness of CPT 58558 and reflect the patient health status and the severity of illness concerning hysteroscopy D&C.

CPT 58558 includes diagnostic hysteroscopy CPT 58555, and inappropriate to report separately. 

If laparoscopy CPT 58541 to CPT 58554 or CPT 58570 to CPT 58578 performs in combination with 58558, it is appropriate to report separately with the proper modifier according to the NCCI.

An excisional biopsy does not report separately if a therapeutic excision performs during the same surgical session. 

When this procedure is performed with another separately identifiable procedure, the highest dollar value code lists as the primary procedure. And following services may append with modifier 51. 

Suppose a hysteroscopy CPT performs with lysis of intrauterine adhesions. It is appropriate to report with CPT code 58559 instead of CPT 58558.

The hysteroscopy D&C procedure has a 0-day global period, and the global period rule does not apply to hysteroscopy procedures. For instance, if the patient had prior service with a 90-day global period, it may require modifier 58 or modifier 79 to show the distinct hysteroscopy procedure. 

Suppose the same physician performs evaluation and management (E/M) service for a reason related to hysteroscopy. It is not appropriate to report E/M CPT code 99202-99499 separately unless the physician decides to perform a hysteroscopy on the same day. 

If the same physician performs E/M CPT 99202 to CPT 99499 for a condition unrelated to surgery, It is appropriate to report with modifier 25.

For instance, the physician performs an office visit about DM2 in the morning and has a later hysteroscopy procedure in the evening. It is appropriate to report the E/M service with modifier 25 to unbundle with the surgical procedure on the same day.

Does CPT 58558 Need A Modifier?

Modifier 52 applies with CPT 58558 when the physician reduces the hysteroscopy procedure with D&C due to unavoidable circumstances if the physician terminates the service due to a drop in the patient’s temperature. If the physician did not state that procedure may resume in three or four months, it might need modifier 52

Modifier 53 applies when the physician terminates the hysteroscopy D&C procedure due to unavoidable circumstances, such as the patient suffering from a hypothermia state. The physician did not reschedule the 58558 CPT code in the future. 

It is appropriate to report modifier 53 with the hysteroscopy D&C procedure after the administration of anesthesia.

Modifier 47 reports can be applied to CPT 58558 when the attending or assistant surgeon administers the anesthesia to the patient during a hysteroscopy D&C procedure.

Modifier 51 is appropriate to report with the hysteroscopy D&C procedure when the physician performs it in addition to another procedure, which is a component of CPT 58558.

Modifier 77 applies to CPT 58558 when a different physician performs the hysteroscopy D&C procedure on the same service date. The patient had a D&C hysteroscopy in the morning and started bleeding later. Another physician performs the procedure to determine the cause of the bleeding.

Modifier 76 is applicable with CPT code 58558 if the same physician repeats the hysteroscopy D&C on the same service date. The patient complains of discomfort in the genital region and redoes the hysteroscopy D&C procedure to identify the reason for the pain.

Modifier 78 can be reported with hysteroscopy D&C CPT code 58558 when the physician performs another procedure during the global period. For example, the patient had the procedure 15 days ago and returned to the operation with an infection at the incision sites.

Modifier 22 can be attached to this code when the physician spends additional time during the procedure. For instance, the physician performs the hysteroscopy D/C procedure on the patient and finds cysts in the female genital area. He removes the cyst in addition and spends supplementary time.

Modifier 79 is applicable with CPT 58558 when the physician performs another procedure in the postoperative period in addition to the hysteroscopy D&C procedure.

For instance, the patient had an arthroscopic procedure on the knee two months ago and had a 90-day global period. The patient started issues related to the female genital region, such as vaginal polyps. Modifier 79 can be reported with this code to get the full reimbursement of hysteroscopy D&C from the insurance or third-party payer.

The patient signs the ABN for a hysteroscopy D&C procedure and can be responsible for the payment if not paid by the insurance. The physician expects that hysteroscopy to be denied by medicare. It applies to reports with the modifier GA

Modifier 80 is applicable to report with this procedure if the assistant surgeon assists and actively participates in the entire service.

58558 CPT Code Reimbursement

A maximum of one unit can be a bill on the same service date of CPT 58558. In contrast, the Three units allow when documentation supports the medical necessity of the service.  

The cost and RUVS of CPT 58558 are $657.38 and 18.99602 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 58558 are $657.38 and 18.99602 when performed in the non-facility.


A thirty-year-old female presents with cancer of the uterus, ovaries, or fallopian tubes. The patient is in chemotherapy treatment and did not receive any improvement. 

The physical exam revealed swelling in the pelvic regions. The physician ordered an X-ray of the pelvis.

 It shows severe infections around the female genital organs. The patient denies other symptoms, such as headache, numbness, urinary problems, nausea, vomiting, and shortness of breath. 

The physician performs the hysteroscopy without D&C (billed with CPT code 58558).

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