Hysteroscopy (Diagnostic and Operative)

CPT 58558 · 4.07 wRVU · 0-day global
CPT58558
wRVU4.07
Global0-day
ApproachEndoscopic
ComplexityModerate
Add-on / Variant CPTs
  • 58555 wRVU: 2.58 — Diagnostic hysteroscopy (separate procedure) — bundled when a surgical hysteroscopy is done the same session; report alone only when diagnostic hysteroscopy is the sole procedure (2.58 wRVU, 0-day global)
  • 58561 wRVU: 6.44 — Hysteroscopy with removal of leiomyomata (submucosal myomectomy) — alternative primary (6.44 wRVU, 0-day global)
  • 58559 wRVU: 5.07 — Hysteroscopy with lysis of intrauterine adhesions (Asherman syndrome) — alternative primary (5.07 wRVU, 0-day global)
  • 58560 wRVU: 5.61 — Hysteroscopy with resection of intrauterine septum — alternative primary (5.61 wRVU, 0-day global)
  • 58562 wRVU: 3.9 — Hysteroscopy with removal of impacted foreign body (e.g., embedded IUD) — alternative primary (3.90 wRVU, 0-day global)
  • 58563 wRVU: 4.36 — Hysteroscopy with endometrial ablation — alternative primary; not for non-hysteroscopic ablation devices (4.36 wRVU, 0-day global)
Preoperative Diagnosis:

[Abnormal uterine bleeding / endometrial polyp / submucosal myoma / retained products / suspected intrauterine adhesions / retained IUD], [with / without] a filling defect on saline infusion sonography or pelvic ultrasound

Postoperative Diagnosis:

Same [/ specific finding: endometrial polyp / type ___ submucosal myoma / intrauterine adhesions]

Procedure Performed:

[Diagnostic / operative] hysteroscopy with [polypectomy / targeted biopsy and D&C / submucosal myomectomy]

Attending Surgeon:

[***, MD/DO]

First Assistant:

[Resident/PA name]

Anesthesia:

[General / monitored anesthesia care with paracervical block]

Indications:

The patient is a [age]-year-old [female] with [abnormal uterine bleeding / a filling defect on imaging / suspected intrauterine pathology] presenting for hysteroscopic evaluation and treatment. The risks, benefits, and alternatives, including the possibility of uterine perforation and fluid absorption, were discussed and informed consent was obtained.

Findings:

The endometrial cavity was systematically surveyed. Both tubal ostia were [visualized bilaterally / not clearly seen]. The endometrium was [normal / atrophic / proliferative]. [A [___]-cm endometrial polyp was identified in the [fundus / posterior wall].] [A type [0 / 1 / 2] submucosal myoma was identified.] [Intrauterine adhesions were present and graded as [mild / moderate / severe].] The total fluid deficit at the end of the case was [___] mL.

Description of Procedure:

The patient was placed in the dorsal lithotomy position and examined under anesthesia. A weighted speculum was placed, the anterior cervical lip was grasped with a tenaculum, and the cervix was dilated as needed to admit the hysteroscope. The distension medium was [normal saline (bipolar or mechanical instruments) / a hypotonic electrolyte-free solution (monopolar instruments)], and fluid inflow and outflow were tracked continuously to monitor the deficit.

The hysteroscope was introduced through the cervical canal under direct vision. A systematic survey of the cavity was performed, inspecting the cervical canal, the fundus, the anterior, posterior, and lateral walls, and both tubal ostia. The findings were documented as above.

[Operative step: the [polyp / submucosal myoma] was resected with a [hysteroscopic tissue morcellator / resectoscope loop] under direct vision, and the specimen was retrieved for pathology. Targeted biopsies of the endometrium were obtained as indicated.] The cavity was re-inspected for residual tissue and hemostasis. Inflow was stopped, the fluid deficit was recorded, and the instruments were removed. The tenaculum site was confirmed hemostatic.

Complications:

None

Specimens:

[Endometrial polyp / submucosal myoma / endometrial curettings / targeted biopsies] sent to pathology

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. [Discharged same day.] Pathology results to guide further management.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** hysteroscopy with ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General / MAC with paracervical block

INDICATIONS: .PTAGE-year-old .PTSEX with *** for hysteroscopic evaluation and treatment. Risks including perforation and fluid absorption discussed. Consent obtained.

FINDINGS: Cavity surveyed. Tubal ostia *** (visualized bilaterally / not seen). Endometrium ***. *** (polyp / type *** submucosal myoma / adhesions). Fluid deficit *** mL.

PROCEDURE:
Dorsal lithotomy, exam under anesthesia. Weighted speculum. Anterior lip on tenaculum. Cervix dilated to admit the scope. Distension medium: *** (saline / hypotonic), inflow and outflow tracked for deficit. Scope introduced under direct vision. Systematic survey: canal, fundus, walls, both ostia. [*** resected with morcellator / resectoscope loop; specimen to pathology. Targeted biopsies as indicated.] Cavity re-inspected for residual tissue and hemostasis. Deficit recorded. Instruments removed. Tenaculum site hemostatic.

SPECIMENS: *** to pathology
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: PACU, stable. Same-day discharge. Pathology to guide management.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Hysteroscopic Polypectomy

A [___]-cm endometrial polyp was identified [in the fundus / on the posterior wall]. It was resected at its base with a [hysteroscopic tissue morcellator / resectoscope loop] under direct vision and retrieved for pathology. The base was inspected and re-treated as needed to remove the stalk. The cavity was re-surveyed to confirm complete removal.

Hysteroscopic Myomectomy (Submucosal Fibroid)

A type [0 / 1 / 2] submucosal myoma was identified. [For type 1 or 2, the intramural component was noted and a plan for possible staged resection was discussed.] The myoma was resected in successive passes with a [resectoscope loop / hysteroscopic morcellator], with attention to the fluid deficit and to avoiding resection into the myometrium. Resection was carried to the level of the surrounding endometrium. The fluid deficit was closely monitored given the deeper resection.

Lysis of Intrauterine Adhesions (Asherman Syndrome)

Intrauterine adhesions were encountered and graded as [mild / moderate / severe]. Adhesions were divided sharply under direct vision with [hysteroscopic scissors], restoring the normal cavity contour and re-establishing visualization of both tubal ostia. [Placement of an intrauterine balloon or planned postoperative estrogen was discussed to reduce reformation.]

Hysteroscopic Removal of Embedded IUD

A [malpositioned / embedded] intrauterine device was identified with [the strings absent / partial myometrial embedding]. The device was grasped under direct vision and freed from the surrounding endometrium and myometrium, then removed intact. The cavity was inspected to confirm no retained fragment and no full-thickness defect.

Charting Tips
  • Document the distension medium and the final fluid deficit. Excessive absorption of a hypotonic, electrolyte-free medium (used with monopolar instruments) can cause hyponatremia and cerebral edema. Case-ending thresholds are commonly set near 1000 to 1500 mL for hypotonic media and near 2500 mL for isotonic saline. State the medium used, the deficit, and any action taken when the deficit rose.
  • Document visualization of both tubal ostia and the systematic survey. The operative record should show that the entire cavity was inspected, since a documented complete survey is what supports that no additional pathology was missed.
  • Document the specific finding and the definitive procedure performed, because the code follows the work. A polyp, biopsy, or D&C maps to 58558, a myoma to 58561, adhesiolysis to 58559, a septum to 58560, and a foreign body to 58562. Vague documentation that does not name the definitive step invites downcoding.
  • Document any concern for uterine perforation. If distension is suddenly lost, the deficit climbs abruptly, or an instrument passes beyond the expected depth, state the finding, how perforation was excluded or managed, and whether the case was terminated.
Billing Tips
  • Bill 58558 for operative hysteroscopy with endometrial biopsy, polypectomy, and/or dilation and curettage (4.07 wRVU, 0-day global). This is the most commonly used operative hysteroscopy code. A concurrent D&C is included in the descriptor, so do not separately report 58120.
  • 58555 (diagnostic hysteroscopy) carries the 'separate procedure' designation. It is bundled when any surgical hysteroscopy is performed at the same session and is reported by itself only when diagnostic hysteroscopy is the only procedure done. Do not bill 58555 in addition to 58558 or another operative hysteroscopy code for the same session.
  • The operative hysteroscopy codes are selected by the definitive work performed, and only one is reported per session: polyp, biopsy, or D&C (58558), submucosal myomectomy (58561, 6.44 wRVU), lysis of intrauterine adhesions (58559, 5.07 wRVU), resection of a uterine septum (58560, 5.61 wRVU), removal of an impacted foreign body such as an embedded IUD (58562, 3.90 wRVU), or endometrial ablation (58563, 4.36 wRVU). Do not stack multiple hysteroscopy codes for one operative session.
  • 0-day global period: a significant, separately identifiable E/M service on the same day may be reported with modifier -25 when documented independently.
  • Non-hysteroscopic (global) endometrial ablation is a different code family with a 10-day global: thermal balloon (58353, 3.51 wRVU) and cryoablation (58356, 6.25 wRVU). Do not report the hysteroscopic ablation code (58563) when a non-hysteroscopic device is used.
  • Hysteroscopic sterilization (58565) reflects the Essure device, which was withdrawn from the U.S. market. Do not use it for current tubal-occlusion practice.

General coding reference. Verify with your institution’s billing department before submitting claims.

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