How To Use CPT Code 58562

CPT 58562 describes the surgical procedure of hysteroscopy with the removal of an impacted foreign body from the lining of the uterus. 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 58562?

CPT 58562 is used to describe a surgical procedure in which a healthcare provider removes a foreign body that has become lodged in the lining of the uterus. The most common impacted foreign body is an intrauterine device (IUD). This procedure is performed using a hysteroscope, a thin, lighted, flexible tube that is inserted through the vagina to view the inside of the uterus.

2. Official Description

The official description of CPT code 58562 is: ‘Hysteroscopy, surgical; with removal of impacted foreign body.’

3. Procedure

1. The patient is placed in the dorsal lithotomy position, and a local or regional anesthetic is administered.
2. The healthcare provider performs a bimanual pelvic exam to assess the size, position, and movement of the uterus.
3. A Foley catheter is inserted to drain the bladder.
4. A speculum is placed into the vagina, and the cervix is dilated as 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 inserted.
6. The provider examines the entire uterine cavity and the endocervical canal using the hysteroscope, while capturing videos of the procedure.
7. The foreign body, such as an IUD, is located and manipulated out of the uterine wall, and then removed from the uterine cavity.
8. Any bleeding that occurs after the removal of the foreign body is managed by the provider.
9. The hysteroscope is removed from the uterus, and the cervix is checked for any bleeding or injury.
10. If necessary, the provider controls any bleeding using sutures, pressure, or cautery.
11. All instruments are removed from the vagina and cervix.

4. Qualifying circumstances

CPT 58562 is performed when a foreign body, such as an IUD, becomes impacted in the lining of the uterus. This procedure is typically performed by a healthcare provider who is experienced in hysteroscopy. The patient may require this procedure due to complications or discomfort caused by the foreign body.

5. When to use CPT code 58562

CPT code 58562 should be used when a healthcare provider performs a hysteroscopy with the specific purpose of removing an impacted foreign body from the uterus. This code should not be used for other hysteroscopy procedures that do not involve the removal of a foreign body.

6. Documentation requirements

To support a claim for CPT 58562, the healthcare provider must document the following information:

• Patient’s diagnosis and the presence of an impacted foreign body
• Details of the hysteroscopy procedure, including the use of a hysteroscope and any additional instruments
• Date of the procedure
• Specific foreign body removed, such as an IUD
• Management of any bleeding or complications
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 58562, ensure that the procedure involves the removal of an impacted foreign body from the uterus using a hysteroscope. It is important to follow the specific documentation requirements and guidelines provided by the payer. CPT code 58562 should not be reported with other hysteroscopy codes unless additional procedures are performed during the same session.

8. Historical information

CPT 58562 was added to the Current Procedural Terminology system on January 1, 2000. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs a hysteroscopy with the removal of an impacted IUD from the uterus of a patient.
2. During a hysteroscopy procedure, a foreign body, such as a contraceptive device, is identified and successfully removed from the uterine cavity.
3. A patient presents with severe pain and discomfort, and a hysteroscopy reveals an impacted foreign body that is promptly removed by the healthcare provider.
4. After experiencing complications with an IUD, a patient undergoes a hysteroscopy procedure to remove the foreign body from the uterus.
5. A healthcare provider performs a hysteroscopy with the removal of an embedded foreign body, providing relief to the patient.
6. During a routine hysteroscopy, a healthcare provider discovers an impacted foreign body and proceeds to remove it from the uterus.
7. A patient with persistent bleeding undergoes a hysteroscopy, which reveals an impacted foreign body that is successfully removed by the healthcare provider.
8. After an unsuccessful attempt to remove an IUD, a patient undergoes a hysteroscopy procedure to safely extract the foreign body from the uterus.
9. A healthcare provider performs a hysteroscopy with the removal of an impacted foreign body, resolving the patient’s symptoms.
10. During a hysteroscopy, a healthcare provider identifies and removes an embedded foreign body, improving the patient’s condition.