2025 CPT code 58561
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Hysteroscopy, surgical; with removal of leiomyomata.
Modifiers may be applicable depending on the specific circumstances of the procedure.For example, modifier 22 (increased procedural services) may be appropriate if the procedure is significantly more complex than usual. Modifier 51 (multiple procedures) might apply if other procedures were performed on the same day. Always consult the appropriate coding guidelines and payer requirements.
Medical necessity for this procedure is typically established when conservative management has failed to alleviate symptoms like abnormal uterine bleeding, pelvic pain, or infertility caused by submucosal fibroids. The documentation should clearly link the symptoms to the presence of the fibroids and demonstrate that the hysteroscopic myomectomy is the medically appropriate treatment option.
The physician is responsible for performing the hysteroscopy, removing the leiomyomata, achieving hemostasis, and managing any complications. This may include pre-operative assessment, obtaining informed consent, performing the procedure, providing post-operative care and follow-up.
In simple words: This surgery uses a thin, lighted tube inserted into the vagina to remove fibroids (non-cancerous growths) from inside the uterus. The doctor uses special instruments to remove the fibroids and stop any bleeding.
This procedure involves a surgical hysteroscopy to remove uterine fibroids (leiomyomata).The physician uses a hysteroscope to visualize and remove the fibroids, often using instruments such as scissors, a wire loop electrode, or laser.Hemostasis is achieved to control bleeding.The procedure may involve dilation of the cervix and the use of a uterine sound to determine uterine depth.The uterine cavity is distended with fluid or air to improve visualization.
Example 1: A 45-year-old woman presents with heavy menstrual bleeding and pelvic pain. Hysteroscopy reveals multiple submucosal leiomyomata.Code 58561 is used to report the surgical hysteroscopic removal of these fibroids., A 38-year-old woman with infertility undergoes a diagnostic hysteroscopy which reveals a large submucosal leiomyoma causing significant uterine distortion.Code 58561 is used to report the subsequent surgical removal of the fibroid., A 50-year-old woman experiences abnormal uterine bleeding. Hysteroscopy shows several small submucosal leiomyomata.The physician performs a hysteroscopic myomectomy to remove the fibroids using a morcellator. Code 58561 is used to bill for the procedure.
Detailed operative report describing the procedure, including the number and size of leiomyomata removed, the methods used, and the amount of bleeding. Preoperative and postoperative diagnoses and assessment. Consent form, pathology reports (if applicable), and any other relevant clinical documentation.
** Always verify the specific requirements of the payer before submitting claims for this procedure.The use of certain devices or techniques may affect coding and reimbursement.Refer to the most up-to-date CPT manual and payer guidelines for the most accurate information.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: The RVUs for this code will vary depending on the payer and the specific circumstances of the procedure.Check the payer's fee schedule for the most accurate information.
- Global Days: The global period for this procedure varies depending on the payer and the complexity of the surgery.Consult the payer's guidelines or the appropriate fee schedule for details.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier does not typically apply to this code.
- Fee Schedule: Historical fee schedules for 58561 can vary greatly depending on the year, payer, and geographic location.To obtain this information for a specific period, it is advisable to consult historical Medicare fee schedules, specific payer fee schedules from past years, or relevant medical billing databases.
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)