CPT Code 58560 Surgical Hysteroscopy with Division or Resection of Intrauterine Septum

Surgical hysteroscopy with division or resection of an intrauterine septum is a minimally invasive procedure designed to correct congenital uterine anomalies. 

A uterine septum can interfere with implantation, cause recurrent pregnancy loss, or lead to abnormal uterine bleeding. 

By visualizing and surgically dividing or removing the septum, physicians restore normal uterine anatomy, improving fertility outcomes and reducing associated complications. Accurate coding, documentation, and billing are critical for OBGYN practices to ensure reimbursement and regulatory compliance.

CPT Code 58560 – Description

The official definition of CPT code 58560 is:

“Hysteroscopy, surgical; with division or resection of intrauterine septum (any method).”

This code describes a therapeutic hysteroscopic procedure in which a hysteroscope is inserted through the cervix to access the uterine cavity. The procedure involves identification and division or resection of a septum using scissors, a resectoscope loop, electrosurgery, or laser. Diagnostic hysteroscopy (CPT 58555) is bundled and not separately reportable during this procedure. CPT 58560 can be reported alongside other hysteroscopic procedures (e.g., CPT 58558, 58559) if each is clearly documented as a distinct service.

The scope includes full visualization of the uterine cavity, septum correction, and restoration of normal intrauterine anatomy.

Scenarios Where CPT Code 58560 Is Applicable

You would bill CPT code 58560 in the following situations:

Correction of Septate Uterus:

When a patient has a septate uterus causing infertility, recurrent pregnancy loss, or abnormal bleeding. The surgeon performs hysteroscopic division or resection of the septum to restore normal uterine anatomy.

Example:

A patient with recurrent miscarriages is diagnosed with a uterine septum via imaging. Hysteroscopic resection of the septum is performed, with documentation of restored uterine cavity and complete septal removal.

Follow-Up Procedures:

CPT 58560 can be used for surgical correction following prior uterine surgeries where residual septum remains, provided documentation supports a distinct therapeutic purpose.

Applicable Modifiers for CPT Code 58560

The following modifiers may be used with CPT code 58560 when appropriate:

Modifier 22 – Increased Procedural Services

Applicable if the septum is extensive, anatomy is challenging, or operative time is significantly above average. Documentation must clearly justify increased effort.

Modifier 51 – Multiple Procedures

Used when CPT 58560 is performed during the same session as another separately reportable hysteroscopic procedure.

Modifier 59 – Distinct Procedural Service

Indicates that another hysteroscopic procedure performed in the same session is clinically and anatomically distinct.

Modifier 25 – Significant, Separately Identifiable E/M Service

Reported if an evaluation and management service is performed on the same day beyond the standard pre- and post-procedure care.

All modifier usage must be fully supported by operative documentation.

CPT Code 58560 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58560, follow these key steps:

Justify Medical Necessity:

Document the clinical indication for septum division or resection, such as infertility, recurrent pregnancy loss, abnormal bleeding, or pelvic discomfort due to septate anatomy.

Use Accurate ICD-10 Codes:

Pair CPT 58560 with diagnosis codes that reflect septate uterus, intrauterine obstruction, or related reproductive issues.

Confirm Procedural Details:

The operative report should include:

• Hysteroscope insertion and uterine cavity access
• Identification and complete division/resection of the septum
• Method used (scissors, resectoscope, electrosurgery, laser)
• Restoration of normal uterine anatomy
• Any operative challenges or complications

Detailed Documentation:

Include intraoperative findings, technique used, and outcomes to support modifiers and payer compliance.

Reimbursement Considerations:

CPT 58560 reimbursement depends on documentation showing therapeutic intervention. Proper coding distinguishes this procedure from diagnostic hysteroscopy (CPT 58555) and ensures payers recognize the clinical and technical complexity, minimizing claim denials.

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BillingFreedom specializes in OBGYN medical billing for complex procedures like CPT 58560. Our expert team is constantly updated on AMA CPT codes, NCCI edits, and payer-specific guidelines to ensure:

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At BillingFreedom, we meticulously review operative notes, verify CPT and modifier selection, and confirm documentation reflects procedural complexity. Partnering with BillingFreedom’s OBGYN medical billing services in Maryland reduces administrative burden, prevents claim denials, and enhances financial performance, allowing healthcare providers to focus on patient care while maximizing revenue.

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