CPT Code 58558 Laparoscopic/Hysteroscopic Procedures on the Corpus Uteri

Accurate coding is essential in gynecologic endoscopy procedures to ensure compliance and correct reimbursement. CPT 58558 is one of the most frequently reported codes for diagnostic and minor operative hysteroscopy procedures. It covers hysteroscopy with endometrial biopsy and/or polypectomy, often performed to evaluate or treat abnormal uterine bleeding, polyps, or infertility.

This guide explains the correct use of CPT 58558, including its definition, coding rules, documentation requirements, modifier use, and reimbursement details,  all aligned with the latest AAPC and CMS updates.

CPT Code 58558 – Description of the Procedure

Official CPT Definition: “Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C.”

In this procedure, the surgeon inserts a hysteroscope,  a thin, lighted instrument,  through the cervix into the uterus to directly visualize the uterine cavity. The physician may take an endometrial biopsy, remove a uterine or endocervical polyp, and/or perform a dilation and curettage (D&C) if clinically indicated.

CPT 58558 is both diagnostic and therapeutic, making it more comprehensive than CPT 58555 (diagnostic hysteroscopy only).

When to Use CPT 58558

CPT 58558 is reported when the provider performs a surgical hysteroscopy for diagnostic purposes and takes an endometrial sample or removes one or more polyps.

Common Indications Include:

• Abnormal uterine bleeding (AUB)
• Suspected or known endometrial polyps
• Postmenopausal bleeding
• Infertility evaluation
• Retained products of conception (POC)
• Incomplete or failed biopsy under office conditions

Do not report this code when:

• Only diagnostic hysteroscopy is performed; use CPT 58555.
• Hysteroscopic myomectomy is performed ,  use CPT 58561.
• The procedure involves resection of the septum or adhesions; use CPT 58559 or 58560 as appropriate.

Coding Guidelines and Billing Instructions

• Report 58558 once per operative session, even if multiple biopsies or polyps are removed.
• Do not separately bill D&C (CPT 58120) when performed as part of this hysteroscopic procedure; it is included in 58558.
• Endocervical curettage performed with hysteroscopy is also bundled.
• If a diagnostic hysteroscopy (58555) is followed by biopsy or polyp removal, report only 58558, as it includes both services.
• The procedure carries a 90-day global period.
• If performed in conjunction with another surgical procedure, apply modifier 51 as appropriate.

Reimbursement and Coverage

Reimbursement for CPT 58558 varies depending on payer, location, and setting:

• Average Medicare (non-facility): $350–$480
• Facility payment: Adjusted due to ASC or hospital reimbursement structure
• Global period: 90 days
• Prior authorization: Often required for hospital-based cases or when performed for abnormal bleeding

Most commercial insurers and Medicare cover hysteroscopic biopsy or polypectomy when medical necessity is clearly documented,  typically supported by diagnoses such as:

• N93.9 – Abnormal uterine and vaginal bleeding, unspecified
• N84.0 – Polyp of corpus uteri
• N97.9 – Female infertility, unspecified
• N85.9 – Noninflammatory disorder of uterus, unspecified

Modifier Use

Use modifiers to clarify service responsibility or multiple procedure scenarios:

• Modifier 51 – Multiple procedures.
• Modifier 52 – Reduced service (if incomplete).
• Modifier 59 – Distinct procedural service, only if separate from another unrelated laparoscopic or hysteroscopic procedure.
• Modifier 22 – Increased procedural services (if surgery was significantly more complex).
• Modifiers 54, 55, 56 – Used for split surgical care as appropriate.

Avoid modifier 59 unless documentation clearly supports a distinct and unrelated service performed during the same session.

Documentation Requirements

Accurate and detailed documentation supports billing accuracy and audit readiness. Your operative note should include:

• Pre- and postoperative diagnoses.
• Clinical indication (e.g., AUB, polyps, infertility).
• Procedure details (instrumentation, findings, actions taken).
• Size, number, and location of polyps or lesions removed.
• Description of tissue samples sent for pathology.
• Anesthesia and intraoperative complications (if any).
• Postoperative plan and follow-up instructions.

Good documentation not only supports reimbursement but also provides protection in case of payer audits.

Example Scenarios

Scenario 1 – Endometrial Biopsy During Hysteroscopy

A patient presents with abnormal uterine bleeding. The provider performs a hysteroscopy under general anesthesia, visualizes the endometrium, and takes multiple targeted biopsies. No additional procedures are performed.

→ Report CPT 58558.

Scenario 2 – Hysteroscopic Polypectomy

A patient with infertility is found to have an endometrial polyp on sonohysterogram. The surgeon performs a hysteroscopic removal of the polyp and sends tissue for pathology.

→ Report CPT 58558 (includes both visualization and polypectomy).

Scenario 3 – Hysteroscopy with Polypectomy and D&C

A postmenopausal patient undergoes hysteroscopy for vaginal bleeding. A single endometrial polyp is resected, and a D&C is performed for additional tissue sampling.

→ Report only CPT 58558, since D&C is included in the procedure.

Each of these examples demonstrates the correct use of 58558 for combined diagnostic and limited therapeutic hysteroscopy cases.

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Our certified coders understand the nuances of endoscopic gynecologic procedures and stay updated with CMS and AAPC changes, ensuring every claim is accurate, compliant, and profitable.

With BillingFreedom’s OBGYN medical billing services, you can expect:

• Reduced denials and resubmissions.
• Proper modifier application and code selection.
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