CPT Code 58301 Complete Billing & Coding Guide for Corpus Uteri

Accurate CPT coding is essential for OBGYN practices to maintain compliance and optimize reimbursement. CPT 58301 is used to report the removal of an intrauterine device (IUD), a routine but important procedure in gynecologic care.

Although this procedure is relatively quick, correct coding, documentation, and billing are crucial to prevent claim denials and ensure proper payment from both commercial and government payers.

CPT Code 58301 – Description

Official Definition: “Removal of intrauterine device (IUD).”

This code is reported when a provider removes an intrauterine contraceptive device, such as a hormonal or copper IUD, from the uterine cavity.

Description of the Procedure

During the procedure, the provider visualizes the cervix using a speculum, locates the IUD strings, and gently withdraws the device from the uterus using forceps. If the strings are not visible, the provider may need to use a cytobrush or small instrument to retrieve them.

If additional effort is required — such as cervical dilation or ultrasound guidance — it should be clearly documented to support the complexity, although no separate CPT code exists for “difficult removal.”

Types of Devices Covered

CPT 58301 applies to both hormonal IUDs (e.g., Mirena®, Kyleena®, Liletta®, Skyla®) and non-hormonal IUDs (e.g., Paragard®). The code covers only the removal procedure, not insertion or device costs.

When to Use CPT 58301

Use CPT 58301 when the provider removes an IUD for reasons such as:

• Expired IUD lifespan
• Desire for pregnancy or discontinuation of contraception
• Device-related complications (pain, bleeding, malposition)
• Infection or uterine perforation (if non-surgical removal is possible)
• Routine exchange for a new IUD

When Not to Use CPT 58301

Do not report 58301 when:

• Both removal and reinsertion are performed at the same visit (use 58300 and 58301, appending modifier 51).
• The IUD cannot be retrieved in-office, and surgical removal (e.g., hysteroscopy) is required — use the appropriate hysteroscopic CPT code instead.

Coding and Billing Instructions - CPT Code 58301 

• CPT 58301 covers removal only — not insertion or device costs.
• If a new IUD is inserted during the same session, report 58300 for insertion, 58301 for removal, and append modifier 51 (if required by payer).
• If an E/M service (e.g., counseling, contraceptive discussion) is performed on the same day, it may be reported separately with modifier 25, provided it is a distinct, medically necessary service.

Global Period and Site of Service

This code has no global surgical period. It is typically performed in an office setting under minimal or no anesthesia. Some payers may require prior authorization for IUD-related services, depending on the contraceptive device policy.

Average Reimbursement Rates

According to the latest Medicare and commercial payer data:

• Average reimbursement for CPT 58301: $60–$85 (varies by region and payer).
• Patient cost-sharing: Usually minimal under most preventive service plans.

When combined with IUD reinsertion or evaluation, ensure each component is properly documented and billed according to payer guidelines.

Device Reimbursement Note

No separate HCPCS code is used for device removal. If a new IUD is placed, the device (e.g., J7300–J7302) should be billed in addition to the insertion procedure (58300).

Common Modifiers Used with CPT 58301

Using modifiers correctly ensures proper claim payment and prevents denials:

• Modifier 25 – When a separately identifiable E/M service is provided at the same encounter.
• Modifier 51 – When IUD removal (58301) and reinsertion (58300) are performed in the same visit.
• Modifier 59 – When removal is performed with another unrelated procedure in the same session.
• Modifier 76 – For repeat IUD removal by the same provider (rare).

Essential Documentation Checklist

For compliance and reimbursement, the following should be clearly documented:

• Reason for IUD removal (expired device, pain, bleeding, etc.)
• Device type and brand removed (if known)
• Method used for removal (visible strings, instrument retrieval, ultrasound-guided)
• Any complications (e.g., broken strings, pain, incomplete removal)
• Patient counseling regarding future contraception or follow-up care
• Patient tolerance and post-procedure instructions

Importance of Clear Documentation

Incomplete notes are a leading cause of payer denials. Detailed operative or progress notes support medical necessity, validate modifier usage, and strengthen claim defensibility during audits.

Example Scenarios

Scenario 1 – Routine IUD Removal

A patient presents for routine removal of a Mirena® IUD after five years of use. The provider removes the IUD easily with visible strings. → Report CPT 58301.

Scenario 2 – Removal and Reinsertion

A patient requests removal of an expired Paragard® IUD and placement of a new Mirena® during the same visit. → Report CPT 58301 and CPT 58300, append modifier 51 if payer requires.

Scenario 3 – Difficult IUD Removal

A patient with non-visible IUD strings requires ultrasound-guided removal. The procedure is successfully completed. → Still report CPT 58301, and include detailed documentation to support complexity.

Why Choose BillingFreedom for OBGYN Billing

Procedures like IUD insertion and removal require precision in coding, documentation, and payer-specific billing practices. BillingFreedom specializes in OBGYN medical billing services, ensuring your claims are compliant, accurate, and timely.

Our certified coders are experts in women’s health billing and stay up to date with the latest CMS and AAPC guidelines. We help OBGYN providers reduce denials, streamline claim processing, and ensure audit-ready documentation.

For more details about our exceptional OBGYN billing services, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472.

Your financial tranquility is our priority!