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CPT Code 58558 | Hysteroscopy With And Without D&C

CPT code 58558 can bill a hysteroscopy procedure that includes an endometrium and/or polypectomy biopsy and is performed with or without Dilation and Curettage (D&C).

What Is CPT Code 58558?

CPT code 58558 describes the procedure of hysteroscopy. This diagnostic and therapeutic procedure allows the provider to visualize and examine the inside of the uterus.

The description of 58558 states that the procedure includes “sampling (biopsy) of the endometrium and/or polypectomy.”

During the biopsy, a small tissue sample is taken from the uterus, specifically the endometrium, for examination under a microscope. This is done to investigate abnormal bleeding, infertility, or recurrent miscarriage.

A polypectomy is a procedure that involves removing polyps, which are small growths on the lining of the uterus, from the uterus.

The description of the CPT code 58558 also states that the procedure may include “with or without D & C, ” meaning that the provider may or may not perform a Dilation and Curettage (D&C).

D&C is a procedure that involves scraping or suctioning the lining of the uterus to obtain tissue samples for pathological analysis.

Description

The CPT book describes CPT code 58558 as: “Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C.”

Procedure

The provider performs a procedure called hysteroscopy. This diagnostic and therapeutic procedure allows the provider to visualize and examine the inside of the uterus.

The provider may choose to either biopsy the lining of the uterus (endometrium), remove polyps, or use a hysteroscope.

He may also perform a dilation and curettage (D&C) if needed. The D&C involves scraping or suctioning the uterus lining to obtain tissue samples for pathological analysis.

Before the procedure, the provider places the patient in the dorsal lithotomy position and administers a local or regional anesthetic.

The provider then performs a bimanual pelvic exam so that he knows the size, position, and movement of the uterus. Next, he inserts a Foley catheter to drain the bladder.

The provider then places a speculum into the vagina and dilates (widens) the cervix if needed so he can insert the hysteroscope into the uterus.

Next, he uses a long, flexible instrument called a uterine sound to determine the depth of the uterus and inserts the hysteroscope.

Then, he removes the speculum and distends the uterine cavity by introducing air or fluid. While taking videos with the hysteroscope in place, the provider examines the entire uterine cavity and the endocervical canal.

If the provider identifies polyps, he dilates the cervix more so he can insert a resectoscope to remove them.

The resectoscope is a specialized instrument that uses electricity to cut and remove the polyp. Once he resects the polyps, he thickens the bleeding points.

The provider then takes a biopsy or scrapes the uterine cavity (or both) using a sharp curette to obtain tissue for pathologic study.

The provider removes the hysteroscope from the uterus and checks the cervix for bleeding from a possible puncture or laceration.

If he identifies any bleeding, he controls it using sutures, pressure, or cautery. He then removes all instruments from the vagina and cervix.

After the 58558 procedure, the patient may experience cramping or mild discomfort for a few days. The results of the pathological analysis will be available in a few days, and the provider will discuss the findings and any necessary follow-up with the patient.

How To Use CPT 58558

Confirm the pathology results, as polyps and fibroids are different conditions before you bill CPT code 58558.

Only use CPT 58558 if the pathology results identify polyps, and use CPT 58561 if the results identify leiomyomata (fibroids).

If the patient has both fibroids and polyps, only report the code for the procedure that removes the fibroids, as it is the more extensive procedure.

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