2025 CPT code 58558

Hysteroscopy with endometrial sampling (biopsy) and/or polypectomy, with or without D&C.

Consult current CPT guidelines for appropriate coding and documentation requirements.Specific guidance on modifiers and unbundling may be found in the American Medical Association (AMA) CPT manual.

Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 59 for distinct procedural service, 25 for significant, separately identifiable E/M service by the same physician on the same day).

Medical necessity is established by the presence of abnormal uterine bleeding, suspected uterine pathology (polyp or fibroid), retained products of conception, or other clinical indications requiring visualization and/or removal of uterine contents.

The physician is responsible for performing the hysteroscopy, taking biopsies, removing polyps, and potentially performing a D&C. This includes patient positioning, administration of anesthesia, dilation of the cervix, insertion and manipulation of the hysteroscope, collection of samples and management of any postoperative bleeding.

IMPORTANT If fibroids and polyps are present, only the code for fibroid removal is reported, representing the more extensive procedure.58561 (removal of leiomyomata) is used for fibroids; 58558 (this code) is used for polyps.

In simple words: This procedure uses a thin, lighted tube inserted into the vagina to examine the inside of the uterus. The doctor may take tissue samples or remove polyps (small growths) from the uterine lining. A D&C (a procedure to scrape the uterine lining) may also be performed.

This procedure involves a hysteroscopic examination of the uterine cavity to visualize and assess the endometrial lining.It may include the removal of polyps (polypectomy) and/or collection of endometrial tissue samples (biopsy) for pathological analysis.A dilation and curettage (D&C) may be performed concurrently depending on clinical needs. The procedure begins with the patient in the lithotomy position, often with regional or local anesthesia. A speculum is used to visualize the cervix which is dilated as needed to facilitate insertion of the hysteroscope into the uterine cavity.The uterine cavity is distended with fluid or gas, allowing for better visualization and polyp resection or biopsy. The hysteroscope, with attached camera, enables the physician to examine the endometrium, identify abnormal areas such as polyps and take targeted biopsies or remove the polyps with surgical instruments passed through the hysteroscope.After the procedure, the instruments are removed, and any bleeding controlled.The collected tissue samples are sent to the laboratory for pathological analysis.

Example 1: A patient presents with abnormal uterine bleeding and a thickened endometrial lining on ultrasound.Hysteroscopy with endometrial biopsy and polypectomy is performed, revealing endometrial hyperplasia and the removal of one polyp. The biopsy results are consistent with the diagnosis., A patient has abnormal uterine bleeding and a suspected polyp identified on ultrasound. A diagnostic hysteroscopy, polypectomy, and endometrial biopsy are performed. The polyp is benign. , Postpartum patient presents with heavy bleeding.A D&C along with a hysteroscopy is performed to remove retained products of conception.

* Preoperative history and physical examination* Indication for the procedure (e.g., abnormal uterine bleeding, suspected polyp, post-partum bleeding)* Ultrasound findings (if any)* Operative report detailing procedure performed, findings, tissue removed and sent for pathology* Pathology report on the tissue samples.

** Always check with payer policies for specific coding guidelines and reimbursement rules.The clinical documentation must clearly support the selected code.

  • Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
  • RVU: Refer to current Medicare Physician Fee Schedule for RVUs and payment rates.RVUs vary based on location and facility type (non-facility vs. facility).
  • Global Days : No global period specified in the provided data.Global period, if applicable, would depend on the payer's policy and specific details of the procedure.
  • Payment Status: Active
  • Modifier TC rule: The provided dataset does not specify whether a technical component modifier applies.
  • Fee Schedule : The provided dataset does not contain historical fee schedule information.Information is available through AMA CPT manual and other official sources.
  • Specialties:Obstetrics and Gynecology
  • Place of Service:Office, Ambulatory Surgical Center, Hospital
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