How To Use CPT Code 58563

CPT 58563 refers to a surgical hysteroscopy procedure with endometrial ablation, used to treat abnormal uterine bleeding. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 58563.

1. What is CPT 58563?

CPT 58563 is a medical procedure code that describes a surgical hysteroscopy with endometrial ablation. This procedure is performed to treat abnormal uterine bleeding by completely destroying the lining of the uterus, known as the endometrium. The procedure is performed using a hysteroscope, a long, flexible instrument that allows the provider to visualize and treat the uterine cavity.

2. 58563 CPT code description

The official description of CPT code 58563 is: “Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)”

3. Procedure

The CPT 58563 procedure involves the following steps:

  1. Placement of the patient in the dorsal lithotomy position and administration of local or regional anesthesia.
  2. Performance of a bimanual pelvic exam to assess the size, position, and movement of the uterus.
  3. Insertion of a Foley catheter to drain the bladder.
  4. Placement of a speculum into the vagina, dilation of the cervix, and curettage to thin the endometrial lining.
  5. Use of a uterine sound to determine the depth of the uterus and insertion of the hysteroscope.
  6. Removal of the speculum and distention of the uterine cavity with air or fluid.
  7. Examination of the entire uterine cavity and endocervical canal using the hysteroscope while taking videos.
  8. Performance of endometrial ablation using a balloon catheter, rollerball, resectoscope, or laser, depending on the chosen method.
  9. Removal of the hysteroscope and checking the cervix for bleeding from possible puncture or laceration, controlling any bleeding as necessary.
  10. Removal of all instruments from the vagina and cervix.

4. Qualifying circumstances

Patients eligible to receive CPT code 58563 services are those who have been diagnosed with abnormal uterine bleeding that has not responded to conservative treatments such as hormonal therapy or dilation and curettage. The procedure is typically recommended for women who have completed childbearing or do not wish to become pregnant in the future, as endometrial ablation may result in infertility or complications during pregnancy.

5. When to use CPT code 58563

CPT code 58563 should be billed when a provider performs a surgical hysteroscopy with endometrial ablation to treat abnormal uterine bleeding. This code is appropriate when the provider has determined that the patient meets the qualifying circumstances and has obtained informed consent for the procedure.

6. Documentation requirements

To support a claim for CPT 58563, the following information should be documented in the patient’s medical record:

  • Patient’s medical history and diagnosis of abnormal uterine bleeding.
  • Conservative treatments attempted and their outcomes.
  • Discussion of the risks, benefits, and alternatives to endometrial ablation, including the potential impact on fertility.
  • Informed consent obtained from the patient.
  • Detailed description of the procedure performed, including the method of endometrial ablation used.
  • Any complications encountered during the procedure and their management.
  • Postoperative care instructions and follow-up plan.

7. Billing guidelines

When billing for CPT code 58563, it is important to follow the specific guidelines and rules set forth by the payer. Some tips for billing this code include:

  • Ensure that the patient’s medical record contains all required documentation to support the claim.
  • Verify that the patient meets the qualifying circumstances for the procedure.
  • Use the appropriate modifiers, if necessary, to indicate any special circumstances related to the procedure.
  • Be aware of any payer-specific rules or requirements for billing CPT 58563.

8. Historical information

CPT 58563 was added to the Current Procedural Terminology system on January 1, 2000. The code was changed on January 1, 2002, with the previous descriptor being “Hysteroscopy, surgical; with endometrial ablation (any method)”.

9. Similar codes to CPT 58563

Five similar codes to CPT 58563 and how they differ are:

  • CPT 58561: This code describes a hysteroscopy with the removal of leiomyomata, which are benign uterine tumors, rather than endometrial ablation.
  • CPT 58562: This code is for a hysteroscopy with the removal of intrauterine foreign body or polyp, not endometrial ablation.
  • CPT 58558: This code refers to a hysteroscopy with biopsy, not endometrial ablation.
  • CPT 58555: This code is for a diagnostic hysteroscopy, which does not involve any surgical intervention or endometrial ablation.
  • CPT 58570: This code describes a total hysterectomy with endometrial ablation, which is a more extensive procedure than CPT 58563.

10. Examples

Here are 10 detailed examples of CPT code 58563 procedures:

  1. A 45-year-old woman with heavy menstrual bleeding unresponsive to hormonal therapy undergoes a hysteroscopy with endometrial ablation using a rollerball.
  2. A 38-year-old woman with abnormal uterine bleeding and a history of failed dilation and curettage has a hysteroscopy with endometrial ablation using a resectoscope.
  3. A 42-year-old woman with menorrhagia and anemia undergoes a hysteroscopy with endometrial ablation using a balloon catheter.
  4. A 47-year-old woman with a history of irregular menstrual cycles and heavy bleeding undergoes a hysteroscopy with endometrial ablation using a laser.
  5. A 40-year-old woman with abnormal uterine bleeding and multiple failed conservative treatments has a hysteroscopy with endometrial ablation using a rollerball.
  6. A 43-year-old woman with heavy menstrual bleeding and a history of failed hormonal therapy undergoes a hysteroscopy with endometrial ablation using a resectoscope.
  7. A 48-year-old woman with menorrhagia and anemia has a hysteroscopy with endometrial ablation using a balloon catheter.
  8. A 41-year-old woman with a history of irregular menstrual cycles and heavy bleeding undergoes a hysteroscopy with endometrial ablation using a laser.
  9. A 46-year-old woman with abnormal uterine bleeding and multiple failed conservative treatments has a hysteroscopy with endometrial ablation using a rollerball.
  10. A 39-year-old woman with heavy menstrual bleeding and a history of failed hormonal therapy undergoes a hysteroscopy with endometrial ablation using a resectoscope.

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