CPT Code 58301 Complete Billing & Coding Guide for Corpus Uteri

Properly coding the CPT is crucial for keeping practices compliant and maximizing reimbursement for OBGYN practices. The removal of an intrauterine device (IUD) is a common yet essential procedure in gynecological care, and is reported using CPT 58301. 

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

The provider uses a speculum to view the cervix, find the IUD strings and carefully remove the IUD from the uterus with the help of forceps. If strings are not visible, the provider may have to use a cytobrush or a small instrument to retrieve the strings. 

If more work must be performed, e.g., cervical dilation or ultrasound guidance, it is mandatory to document this to justify complexity, but there is no specific CPT code for the term “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 

• If a new IUD is inserted at the same time, report 58300 for insertion, 58301 for removal, and include modifier 51 (as needed by the payer).
• When an E/M service (counseling, contraceptive discussion) is rendered on the same date, may be separately reported with modifier 25 if it is a separate and medically necessary service.

Global Period and Site of Service

This code has no global surgical period. It is commonly done in an office environment with little or no anesthesia. Depending on the contraceptive device policy, some services involving IUDs may need prior authorization from some payers. 

Average Reimbursement Rates For CPT Code 58301

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.

In conjunction with IUD reinsertion or evaluation, make sure to document and bill each component of the evaluation correctly per payer rules. 

Device Reimbursement Note

There is no HCPCS code for device removal. When a new IUD is inserted, the IUD (58300) insertion procedure should be billed with the device (e.g., J7300-J7302). 

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 CPT Code 58301

The following is a list of common modifiers with CPT 58301: 

• Reason for IUD removal (expired device, pain, bleeding, etc.)
• Device type and brand removed (if known)
• Method used to remove (visible string, instrument retrieval, ultrasound guided)
• Any complications such as broken strings, pain, or incomplete removal
• Providing patient education about future contraception or follow-up care
• Patient tolerance and post-procedure instructions

Importance of Clear Documentation

One of the top reasons for payer denials is due to incomplete notes. Operative notes or progress notes provide detail to support the medical necessity, validate modifier use, and improve claim defensibility during an audit. 

Example Scenarios For CPT Code 58301

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

The patient comes in for the removal of an old Paragard® IUD and insertion of a new Mirena® on the same visit. → Report CPT 58301 and CPT 58300, append modifier 51 if payer requires.

Scenario 3 – Difficult IUD Removal

When the IUD (string) is not visible, it must be removed under ultrasound. The procedure is successfully completed.  → Still report CPT 58301, and include detailed documentation to support complexity.

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Certain procedures, such as insertion and removal of IUDs, demand accuracy in coding, documentation, and payer-specific billing methods. BillingFreedom's services focus on OB/GYN medical billing, making sure claims are accurate, complete and on time. 

Our certified health care billers are up to date with AAPC and CMS guidelines and have extensive knowledge of women's health billing. We assist OBGYN providers with claim denials, claim processing, and documentation that is prepped for audits. 

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