Current Procedural Terminology (CPT) codes are a standardized language used by healthcare providers to communicate medical services and procedures to insurance payers. These five-digit codes help determine appropriate reimbursement. CPT code 58558 identifies a hysteroscopic procedure performed on the uterus, representing a surgical intervention rather than a purely diagnostic one. The full description of 58558 covers a surgical hysteroscopy that includes tissue sampling from the uterine lining. This code is used when a physician performs a visual examination that immediately leads to a procedure like a biopsy or polyp removal.
Defining Diagnostic Hysteroscopy
A hysteroscopy is a minimally invasive procedure that uses a thin, lighted instrument called a hysteroscope to view the inside of the uterus. The hysteroscope is gently inserted through the vagina and the cervix to visualize the endometrial cavity. When the procedure is purely diagnostic, the physician’s only goal is to look for abnormalities or structural issues.
CPT code 58558 is formally defined as “Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C (Dilation and Curettage)”. This means the physician performed the initial visual inspection, found a condition requiring action, and proceeded to perform a surgical step within the same session. The procedure transitions from a simple look to an operative intervention, such as removing polyps or taking a tissue sample.
Common Reasons for the Procedure
Physicians order the initial hysteroscopic examination, which may result in the use of CPT 58558, primarily to investigate specific symptoms or abnormal findings. The most common indication is abnormal uterine bleeding, including heavy menstrual periods, irregular spotting, or any bleeding after menopause. These symptoms often signal a need to inspect the endometrial lining for potential issues.
The procedure is also used to evaluate the uterine cavity in cases of infertility or recurrent miscarriage. Structural abnormalities, such as uterine polyps, submucosal fibroids, or thickened endometrial tissue seen on an ultrasound, are frequent targets for the surgical component of 58558. Removing a polyp (polypectomy) or taking a biopsy allows for a definitive diagnosis and often treats the underlying cause of the bleeding simultaneously.
What to Expect During and After
The surgical hysteroscopy associated with CPT 58558 is often performed in an outpatient setting, such as a surgical center or hospital. Anesthesia may range from local anesthesia to moderate or general sedation, depending on complexity and patient preference. To allow for better visualization, the physician expands the uterine cavity using a liquid solution like saline.
The procedure itself typically takes between 30 minutes to one hour, depending on whether a biopsy, polypectomy, or dilation and curettage is performed. Recovery time is slightly longer than for a purely diagnostic procedure. Most patients can expect to return to their normal activities within one to two days.
It is common to experience mild, period-like cramping and light spotting or bleeding for a few days after the procedure. Over-the-counter pain relievers are usually sufficient to manage discomfort. Patients are advised to avoid strenuous activities and refrain from inserting anything into the vagina for a short period to allow for complete healing.
Understanding the “Separate Procedure” Designation
The concept of a “separate procedure” is a billing and coding rule that prevents the over-billing of services inherently part of a larger operation. The diagnostic hysteroscopy code (CPT 58555) carries this designation because it is typically included in any more comprehensive surgical procedure. If a physician simply looks inside the uterus and does nothing else, they bill the diagnostic code.
If the physician performs the visual examination and immediately proceeds to take a biopsy or remove a polyp, they have performed the surgical procedure covered by CPT 58558. In this situation, the diagnostic look is considered an inherent component of the surgical intervention. Therefore, the diagnostic code (58555) is “bundled” into the surgical code (58558), and only the surgical code is reported to the payer. This rule ensures that only the single, most comprehensive procedure performed is charged.