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CPT Code 58563 | Hysteroscopy With Endometrial Ablation

CPT 58563 describes a surgical procedure called a hysteroscopy with endometrial ablation, which involves examining and treating abnormalities in the uterus using heat or a laser.

What Is CPT Code 58563?

CPT code 58563 describes a surgical procedure called a hysteroscopy with endometrial ablation.

CPT 58563 involves examining the uterus and destroying the uterine lining using heat or a laser to treat abnormal bleeding or other abnormalities in the lining.

The procedure begins by administering an anesthetic and inserting a hysteroscope to examine the uterus.

The provider may then use a thermoablation procedure with a balloon catheter or a laser to destroy the uterine lining. The provider may also check for and control any bleeding before removing all instruments.

Description

The CPT book describes CPT code 58563 as: “Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation).”

Procedure

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

The provider 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 places a speculum into the vagina, dilates or widens the cervix, and performs curettage to thin the endometrial lining.

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

He removes the speculum and distends, or expands, 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.

Once the examination is complete, he may insert a balloon catheter in a thermoablation procedure.

He inflates the catheter, and once he knows it is correctly inflated, he fills it with fluid so that the balloon expands to fill the entire uterine cavity. He then heats the liquid, which takes about four minutes.

He then leaves the balloon in the uterus for eight minutes to ensure he destroys the uterine lining. Next, the provider lets the fluid cool for about thirty seconds, then removes the balloon from the uterus.

Alternatively, the provider may coagulate the entire cavity using a rollerball, a resectoscope, or a laser.

When he destroys all the linings, 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.

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