CPT 58561: Coding Hysteroscopic Fibroid Removal

Coding fibroid removal requires a close look at the operative report. The report should explain how the surgery was performed, what tissue was removed, and what the physician found during the procedure. For OB/GYN practices and ambulatory surgical centers (ASCs), knowing the difference between diagnostic hysteroscopy and surgical fibroid removal helps prevent coding mistakes and duplicate billing.

A Case of Submucosal Fibroid Removal

In a September 28, 2026 coding example, AAPC discusses the case of a 42-year-old patient with heavy menstrual bleeding, infertility, and recurrent pregnancy loss.

A saline infusion sonohysterography shows a 2.4 cm submucosal fibroid inside the uterine cavity, causing it to change shape. The gynecologist later removes the fibroid using a hysteroscope at an ambulatory surgical center.

Why CPT 58561 Applies

CPT 58561 is used for surgical hysteroscopy involving the removal of uterine fibroids (leiomyomata). Since the physician removed the fibroid through hysteroscopy, CPT 58561 is the appropriate code for this procedure.

The patient’s age, fibroid size, symptoms, or surgical setting alone don’t determine the procedure code. What matters is the surgery documented in the operative report.

The sonohysterography helps identify the fibroid, while the hysteroscopic surgery removes it. Although these are different procedures, whether both are separately payable depends on the payer’s billing rules.

What to Check in the Operative Report

Before billing CPT 58561, review the operative report for the following details:

• The fibroid location and findings inside the uterine cavity.
• Confirmation that the physician used a hysteroscopic approach.
• A description of the procedure and the fibroid tissue removed.
• Medical reason for performing the surgery.

These details help the billing team understand what was performed. They aren’t a separate list of mandatory CPT documentation requirements.

If the report doesn’t clearly describe the surgery, ask the physician for clarification. Don’t rely on imaging results alone to determine what happened during the procedure.

Common CPT 58561 Coding Mistakes

Don’t confuse CPT 58561 with codes for other surgical approaches or endometrial polyp removal. Even when patients have similar symptoms, the procedure performed determines which code applies.

Another mistake is billing diagnostic hysteroscopy separately when it’s part of the surgical procedure.

According to CMS’s 2026 Medicare NCCI Policy Manual, Section E.2, diagnostic hysteroscopy (CPT 58555) is included in surgical hysteroscopy codes 58558–58565.

For more information about diagnostic hysteroscopy, see BillingFreedom’s CPT 58555 coding guide.

Review imaging and other services provided during the surgery before billing them separately. Check payer guidelines and coding edits to confirm whether separate billing and payment are allowed.

Payer and ASC Billing Requirements

Before submitting a claim, check the patient’s coverage, prior authorization requirements, coding edits, and billing rules for the date of service.

Physician and ASC facility claims have different billing requirements, even when they relate to the same procedure.

The Medicare Claims Processing Manual explains how Medicare handles ASC facility services separately from physician services.

Commercial insurers may have different requirements, so review their policies before filing claims. Using the correct CPT code doesn’t always mean the claim will be paid.

Common Questions About CPT 58561

What Records Should the Billing Team Keep for an Appeal?

Keep the original claim, remittance notice, operative report, relevant medical records, and all correspondence with the payer.

If the claim is denied, review the denial reason and follow the payer’s appeal process within the required deadline. The appeal should address the specific issue the insurer raised.

Does a 2.4 cm Fibroid Require a Different CPT Code?

No. The fibroid’s size alone doesn’t determine the CPT code in this example.

When the operative report confirms that the physician removed a leiomyoma hysteroscopically, CPT 58561 applies.

Can CPT 58555 Be Billed Separately With CPT 58561?

No, not when diagnostic hysteroscopy is performed as part of the same surgical hysteroscopy.

Under Medicare NCCI guidelines, diagnostic hysteroscopy (58555) is included in surgical hysteroscopy procedures reported with CPT 58558–58565.

What This Means for Your Practice

Your OB/GYN billing teams should review operative reports and related charges before filing hysteroscopic procedure claims. Check the following to prevent coding errors and reduce claim denials:

• Review the operative report. Make sure the physician removed fibroid tissue through hysteroscopy before assigning CPT 58561. Fibroid size, symptoms, and imaging results alone aren’t enough to select the procedure code.
• - Review missing surgical details. If the operative report doesn't clearly state how the surgery was performed or what tissue was removed, check with the physician. Don't use a polypectomy code or rely only on preoperative imaging to determine the procedure.
• Check for duplicate hysteroscopy charges. Review charge templates to make sure diagnostic hysteroscopy isn’t billed separately when it’s included in the surgical procedure under Medicare NCCI rules.
• Review other services billed. Check sonohysterography and any related procedures against payer policies and coding edits. Just because a service has a different clinical purpose doesn’t mean it qualifies for separate payment.
• Review physician and ASC claims. Check coverage, prior authorization, documentation, and service-date rules for each claim. Follow commercial payer requirements separately from Medicare guidelines.
• Review denied claims. Check why the claim was denied and gather the operative report, original claim, remittance notice, and payer correspondence. Make corrections or file an appeal within the payer’s deadline.

Need Help With Hysteroscopic Procedure Billing?

Coding mistakes, incomplete operative reports, and overlooked payer rules can lead to claim denials and delayed payments.

BillingFreedom provides OB/GYN medical billing services to help practices review medical records, check procedure codes, and follow up with payers on billing issues.

Our team identifies coding inconsistencies and prepares claims according to applicable billing requirements.

Contact BillingFreedom today to review your hysteroscopic procedure billing process and address issues that may be affecting reimbursement.

References

• AAPC: Fibroid Resection Coding Guide — September 28, 2026.
• CMS: Medicare NCCI Policy Manual (2026), Chapter VII — Section E.2.
• CMS: Medicare Claims Processing Manual, Chapter 14 — Section 10.4.