How To Use CPT Code 58565

CPT 58565 describes a surgical procedure that involves the placement of coils into both fallopian tubes to induce occlusion and prevent pregnancy. 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 58565?

CPT 58565 can be used to describe a surgical procedure in which the provider places coils into both fallopian tubes to induce occlusion and prevent pregnancy. This code is used when the 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 58565 is: ‘Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants.’

3. Procedure

1. The provider places the patient in the dorsal lithotomy position and administers 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 is inserted to drain the bladder.
4. A speculum is placed 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 inserted.
6. The uterine cavity is distended with air or fluid, and the provider examines the entire uterine cavity and the endocervical canal.
7. The provider visualizes the fallopian tube openings and places the coils into the fallopian tubes using a catheter.
8. The hysteroscope is removed from the uterus, and the cervix is checked for any bleeding.
9. If bleeding is present, it is controlled using suture, pressure, or cautery.
10. All instruments are removed from the vagina and cervix.

4. Qualifying circumstances

CPT 58565 is performed on patients who require sterilization to prevent pregnancy. The procedure involves the placement of coils into both fallopian tubes to induce occlusion. It is important to note that CPT 58565 should not be reported in conjunction with CPT 58555 or CPT 57800. If the procedure is performed unilaterally, modifier 52 should be used.

5. When to use CPT code 58565

CPT code 58565 should be used when a provider performs a surgical procedure to induce occlusion of both fallopian tubes using coils. It should not be used in conjunction with CPT codes 58555 or 57800. If the procedure is performed unilaterally, modifier 52 should be used.

6. Documentation requirements

To support a claim for CPT 58565, the provider must document the following information:

• Patient’s diagnosis and the need for sterilization
• Details of the procedure, including the use of a hysteroscope and the placement of coils into both fallopian tubes
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 58565, ensure that the procedure is performed using a hysteroscope and involves the placement of coils into both fallopian tubes. Do not report CPT 58565 in conjunction with CPT 58555 or CPT 57800. If the procedure is performed unilaterally, modifier 52 should be used.

8. Historical information

CPT 58565 was added to the Current Procedural Terminology system on January 1, 2005. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants for a patient who desires permanent sterilization.
2. A patient undergoes a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants as a method of contraception.
3. A provider performs a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants for a patient who has completed her desired number of pregnancies.
4. A patient undergoes a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants as a method of family planning.
5. A provider performs a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants for a patient who has a medical condition that contraindicates other forms of contraception.
6. A patient undergoes a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants as a method of permanent birth control.
7. A provider performs a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants for a patient who desires a non-hormonal form of contraception.
8. A patient undergoes a hysteroscopy with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants as a method of long-term contraception.