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CPT Code 58555 Diagnostic Hysteroscopy (Separate Procedure)

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Diagnostic hysteroscopy is a key minimally invasive procedure in gynecology that allows direct visualization of the uterine cavity. 

It is frequently used when non-invasive imaging, such as ultrasound or hysterosalpingography (HSG), is inconclusive, or when structural abnormalities are suspected. 

The procedure provides critical information for evaluating abnormal uterine bleeding, infertility, recurrent pregnancy loss, or other intrauterine conditions, allowing clinicians to make targeted treatment decisions. Its minimally invasive nature reduces patient risk while improving diagnostic accuracy

CPT Code 58555 – Description

The official definition of CPT code 58555 is:

“Hysteroscopy, diagnostic (separate procedure); uterine cavity evaluation without operative intervention.”

This code describes a minimally invasive diagnostic procedure in which a hysteroscope is inserted through the vagina and cervix to directly visualize the uterine cavity, endometrium, and tubal ostia. No operative intervention, such as biopsy, polypectomy, or D&C, is performed during this procedure.

The scope of CPT 58555 includes cervical access, uterine cavity distension (using saline or CO₂), direct visualization of intrauterine structures, and recording findings for clinical assessment and follow-up.

Scenarios Where CPT Code 58555 Is Applicable

You would bill CPT code 58555 in the following situations:

Initial Diagnostic Assessment:

When a patient requires direct visualization of the uterine cavity without any operative intervention.

Example:

A patient presents with abnormal uterine bleeding. The physician performs a diagnostic hysteroscopy to examine the endometrium and tubal ostia but does not perform a biopsy or remove any polyps.

Standalone Procedure Only:

CPT 58555 is billable only when performed independently, not bundled with operative hysteroscopic procedures (e.g., biopsy or polypectomy performed during the same session, such as CPT 58558).

Clinical Documentation:

The operative note should document uterine access, visualization of intrauterine structures, and findings without any therapeutic intervention.

Applicable Modifiers for CPT Code 58555

The following modifiers may be used with CPT code 58555 when appropriate:

Modifier 59 – Distinct Procedural Service

Indicates that the diagnostic hysteroscopy was a separate procedure from any other interventions performed during the same encounter.

Modifier 52 – Reduced Services

Used if the procedure was partially completed or limited due to patient factors, such as intolerance or anatomical constraints.

Modifier 25 – Significant, Separately Identifiable E/M Service

Reported if an evaluation and management service was provided on the same day as the procedure, beyond the usual pre- and post-procedure care.

All modifier usage must be clearly supported by documentation.

CPT Code 58555 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58555, follow these key steps:

Justify Medical Necessity:

Document the clinical indication for performing a purely diagnostic hysteroscopy, such as abnormal uterine bleeding, infertility evaluation, or intrauterine abnormalities observed on imaging.

Use Accurate ICD-10 Codes:

Pair CPT 58555 with diagnosis codes that reflect the clinical reason for the diagnostic hysteroscopy.

Confirm Procedural Details:

The operative report should clearly document:

  • Cervical access and uterine cavity distension
  • Visualization of endometrium, tubal ostia, and intrauterine structures
  • Confirmation that no operative intervention was performed

Detailed Documentation:

Ensure that findings and observations are recorded to support medical necessity and payer compliance.

Reimbursement Considerations:

Because CPT 58555 is a standalone diagnostic procedure, reimbursement is generally lower than operative hysteroscopic codes. Accurate documentation ensures claims are processed correctly and prevents denials for unbundling with surgical interventions.

BillingFreedom – Expert OBGYN Medical Billing Services

Billingfreedom, as well known for its OBGYN medical billing services in Georgia, brings deep expertise in coding and documentation for procedures like CPT 58555. Our certified specialists stay up to date with AMA, AAPC, and payer guidance to ensure every claim meets regulatory and payer requirements.

Performance metrics:

We meticulously review operative notes, validate CPT and modifier selection, and ensure documentation supports diagnostic intent. By partnering with our expert team, OB-GYN practices reduce administrative burden, prevent denials, and maximize revenue. The combination of accuracy, compliance, and technical expertise allows healthcare providers to focus on patient care while maintaining strong financial performance.

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

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