How To Use CPT Code 58559

CPT 58559 describes a surgical procedure called hysteroscopy with lysis of intrauterine adhesions. This article will provide an overview of the code, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 58559?

CPT 58559 is used to describe a surgical procedure known as hysteroscopy with lysis of intrauterine adhesions. This procedure involves the removal or separation of scar tissue that has formed inside the uterine cavity. It is performed using a hysteroscope, which is a thin, lighted tube that is inserted through the vagina to view the inside of the uterus.

2. Official Description

The official description of CPT code 58559 is: ‘Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method).’ This code encompasses the surgical procedure of breaking down or separating scar tissue that has formed inside the uterine cavity using a hysteroscope.

3. Procedure

1. The patient is placed in the dorsal lithotomy position and may be given a local or regional anesthetic.
2. A bimanual pelvic exam is performed to assess the size, position, and movement of the uterus.
3. A Foley catheter may be inserted to drain the bladder.
4. A speculum is inserted into the vagina, and the cervix is dilated if necessary to allow for the insertion of the hysteroscope.
5. A uterine sound is used to determine the depth of the uterus, and the hysteroscope is then inserted.
6. The uterine cavity is distended with air or fluid, and the provider examines the entire uterine cavity and endocervical canal using the hysteroscope.
7. The cervix is further dilated to allow for the insertion of a resectoscope, which is used to lyse the adhesions from the interior of the uterus using scissors or a laser.
8. Bleeding points are coagulated, and any bleeding from the cervix is controlled.
9. All instruments are removed, and a device like a Foley catheter may be placed in the uterine cavity to promote healing.

4. Qualifying circumstances

CPT 58559 is performed on patients who have developed scar tissue, known as adhesions, inside the uterine cavity. These adhesions can form as a result of previous surgery or injury. The procedure is typically performed by a healthcare provider who specializes in gynecology or reproductive medicine. It is important to note that the procedure may vary depending on the specific circumstances of the patient and the provider’s preferred method of lysis.

5. When to use CPT code 58559

CPT code 58559 should be used when a hysteroscopy is performed specifically for the purpose of lysing intrauterine adhesions. It is important to ensure that the procedure is documented accurately and that the medical necessity for the lysis of adhesions is clearly indicated. This code should not be used for other hysteroscopy procedures that do not involve the lysis of intrauterine adhesions.

6. Documentation requirements

To support a claim for CPT code 58559, the following documentation is typically required:

• Documentation of the patient’s diagnosis and the medical necessity for the procedure
• Description of the specific method used for lysis of intrauterine adhesions
• Date of the procedure and the duration of the surgery
• Details of the procedure, including the use of a hysteroscope, any additional instruments used, and the steps taken to lyse the adhesions
• Documentation of any complications or unexpected findings during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 58559, it is important to ensure that the procedure is accurately documented and coded. The procedure should be performed by a qualified healthcare provider, such as a gynecologist or reproductive medicine specialist. It is also important to follow any specific billing guidelines provided by the payer or insurance company. It is recommended to review the specific guidelines and requirements for billing CPT code 58559 to ensure proper reimbursement.

8. Historical information

CPT code 58559 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 undergoes hysteroscopy with lysis of intrauterine adhesions to address fertility issues caused by scar tissue.
2. A woman with a history of multiple miscarriages undergoes hysteroscopy with lysis of intrauterine adhesions to improve her chances of a successful pregnancy.
3. A patient experiences abnormal uterine bleeding and undergoes hysteroscopy with lysis of intrauterine adhesions to identify and treat the underlying cause.
4. A woman with a history of pelvic inflammatory disease undergoes hysteroscopy with lysis of intrauterine adhesions to alleviate symptoms and improve reproductive health.
5. A patient with a previous cesarean section develops intrauterine adhesions and undergoes hysteroscopy with lysis to restore normal uterine function.
6. A woman with a history of endometriosis undergoes hysteroscopy with lysis of intrauterine adhesions to improve fertility outcomes.
7. A patient experiences recurrent urinary tract infections and undergoes hysteroscopy with lysis of intrauterine adhesions to address the underlying cause.