2025 CPT code 58555
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Diagnostic hysteroscopy (separate procedure).
Modifiers may be applicable depending on the circumstances of the procedure. For example, modifier 59 (distinct procedural service) may be used if the hysteroscopy is performed as a separate and distinct procedure from other services performed on the same day.
Medical necessity for a diagnostic hysteroscopy is established when there is a clinical indication, such as abnormal uterine bleeding, suspected uterine pathology, or evaluation of infertility. The procedure should be supported by appropriate clinical findings and documented in the medical record.
The physician or qualified healthcare professional performs the hysteroscopy, including patient positioning, anesthesia administration (if necessary), insertion of the hysteroscope, visualization of the uterine cavity, collection of any tissue samples, and post-procedure monitoring.
In simple words: The doctor uses a thin, lighted tube with a camera to look inside the uterus to check for problems like polyps or fibroids.This helps diagnose the cause of any abnormal bleeding.
Diagnostic hysteroscopy is a procedure involving the insertion of a hysteroscope, a thin, lighted, flexible tube, through the vagina and cervix into the uterus.A fluid or gas is used to distend the uterine cavity for better visualization. The procedure allows for examination of the uterine cavity and endocervical canal, enabling the diagnosis of uterine conditions such as polyps, fibroids, adhesions, or other abnormalities.It may involve taking tissue samples (biopsy).
Example 1: A 45-year-old female patient presents with abnormal uterine bleeding. A diagnostic hysteroscopy is performed to identify the cause of the bleeding.The procedure reveals a uterine polyp, which is then removed (coded separately)., A 30-year-old patient experiencing infertility undergoes a diagnostic hysteroscopy to rule out uterine abnormalities that might affect fertility. The hysteroscopy reveals no significant findings., A 60-year-old postmenopausal woman reports postmenopausal bleeding.A diagnostic hysteroscopy is performed to evaluate the uterine lining and exclude endometrial cancer.
* Complete patient history including presenting symptoms, relevant medical history, and any previous treatments.* Detailed operative report describing the procedure, findings, and any specimens collected.* Pathology report if a biopsy was performed.* Any imaging studies (e.g., ultrasound) performed prior to the hysteroscopy.* Documentation of the anesthesia administered (if applicable).* Informed consent form signed by the patient.
** This code is for diagnostic hysteroscopy only.If any therapeutic interventions are performed during the procedure, additional codes will be required to accurately reflect the services provided.Always refer to the most current coding guidelines and payer specific rules.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: The RVUs for this code will vary based on several factors, including geographic location and facility type. Consult a relevant fee schedule for specific values.
- Global Days: Not applicable for this diagnostic procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable for a diagnostic hysteroscopy; this is a professional service.
- Fee Schedule: Fee schedules vary significantly by payer and geographic location.Consult the appropriate fee schedule for the specific period of interest. Data not available in provided sources.
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)