How To Use CPT Code 58558

CPT 58558 describes the surgical procedure of hysteroscopy, which involves the sampling (biopsy) of the endometrium and/or polypectomy. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58558?

CPT 58558 is a code used to describe a surgical procedure called hysteroscopy. This procedure involves the sampling (biopsy) of the endometrium, which is the lining of the uterus, and/or the removal of polyps. The provider uses a hysteroscope, a thin, lighted, flexible tube, to visualize the inside of the uterus and perform the necessary interventions.

2. Official Description

The official description of CPT code 58558 is: ‘Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C.’ This code encompasses the surgical procedure of hysteroscopy, including the sampling of the endometrium and/or the removal of polyps. It may or may not involve a dilation and curettage (D & C).

3. Procedure

1. The patient is positioned in the dorsal lithotomy position, lying on her back with knees bent and spread apart using stirrups.
2. The provider administers a local or regional anesthetic to ensure the patient’s comfort during the procedure.
3. A bimanual pelvic exam is performed to assess the size, position, and movement of the uterus.
4. A speculum is inserted into the vagina to hold the vaginal walls apart, allowing the provider to access the cervix.
5. If necessary, the provider dilates the cervix to create a wider opening for the hysteroscope.
6. The provider inserts the hysteroscope into the uterus and uses a uterine sound to determine the depth of the uterus.
7. The uterine cavity is distended by introducing air or fluid, allowing the provider to visualize the entire uterine cavity and the endocervical canal.
8. If polyps are identified, the provider may further dilate the cervix to insert a resectoscope, a surgical instrument used to remove the polyps.
9. The provider removes the polyps and coagulates any bleeding points.
10. If a biopsy of the endometrium is needed, the provider uses a sharp curette to scrape the uterine cavity and obtain tissue samples.
11. The hysteroscope is removed from the uterus, and the cervix is checked for any bleeding or complications.
12. If necessary, the provider controls any bleeding using sutures, pressure, or cautery.
13. All instruments are removed from the vagina and cervix, and the procedure is completed.

4. Qualifying circumstances

CPT 58558 is performed on patients who require the sampling of the endometrium and/or the removal of polyps. The procedure is typically indicated for patients with abnormal uterine bleeding, suspected endometrial pathology, or the presence of uterine polyps. The provider must assess the patient’s condition and determine the need for hysteroscopy and the specific interventions required.

5. When to use CPT code 58558

CPT code 58558 should be used when a provider performs a hysteroscopy procedure that involves the sampling of the endometrium and/or the removal of polyps. This code is appropriate when the procedure is performed with or without a dilation and curettage (D & C). It is important to accurately document the specific interventions performed during the hysteroscopy to support the use of this code.

6. Documentation requirements

To support a claim for CPT 58558, the provider must document the following information:

• Patient’s condition and the need for hysteroscopy
• Specific interventions performed, such as sampling of the endometrium and/or polypectomy
• Use of a hysteroscope and any additional instruments used
• Date and duration of the procedure
• Any complications or additional procedures performed
• Pathological analysis of the samples obtained, if applicable
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 58558, ensure that the procedure meets the criteria for hysteroscopy with sampling of the endometrium and/or polypectomy. It is important to accurately document the specific interventions performed during the procedure to support the use of this code. Additionally, be aware of any bundling or unbundling rules that may apply to this code and follow the appropriate billing guidelines provided by payers.

8. Historical information

CPT 58558 was added to the Current Procedural Terminology system on January 1, 2000. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with abnormal uterine bleeding undergoes hysteroscopy with sampling of the endometrium to assess for endometrial pathology.
2. A postmenopausal woman with suspected uterine polyps undergoes hysteroscopy with polypectomy to remove the polyps and obtain tissue samples for pathological analysis.
3. A patient with a history of infertility undergoes hysteroscopy with sampling of the endometrium to evaluate the uterine lining for potential implantation issues.