CPT Code 58561 Hysteroscopy, Surgical; With Removal Of Leiomyomata

For any hysteroscopic procedure, including therapeutic, such as removing fibroids, accurate coding is crucial when making a claim. Hysteroscopic myomectomy is a minimally invasive surgical procedure that is used to remove fibroids (leiomyomas) that occur inside the uterine cavity, as described by CPT 58561. 

Due to the possibility that this procedure may be performed in conjunction with a diagnostic and/or other therapeutic hysteroscopy codes, code selection and documentation are very important to ensure proper reimbursement and adherence to the payers' rules. 

CPT Code 58561 – Description of the Procedure

Official CPT Definition: “Hysteroscopy, surgical; with removal of leiomyomata.”

This code represents the use of a hysteroscope to visualize and surgically remove one or more fibroids located within the uterine cavity (submucosal myomas). The surgeon inserts the hysteroscope through the cervix, identifies the fibroids, and removes them using resectoscopic instruments, such as a loop electrode or morcellator.

Unlike abdominal or laparoscopic myomectomy (codes 58146 or 58546), CPT 58561 is specific to intrauterine (hysteroscopic) fibroid removal, which preserves the uterus and is often performed on an outpatient basis.

When to Use CPT 58561

CPT 58561 is used for the removal of one or more fibroids from the uterus using a hysteroscopic technique, usually for therapeutic reasons, and not for diagnosis. 

Appropriate clinical indications include:

• Abnormal uterine bleeding (AUB) due to submucosal fibroids.
• Infertility or recurrent pregnancy loss caused by fibroid distortion of the uterine cavity.
• Dysmenorrhea or pelvic pain linked to intracavitary fibroids.
• Incomplete removal of fibroids following previous D&C or hysteroscopic procedures.

Do not report this code when:

• Only a diagnostic hysteroscopy is performed - use CPT 58555.
• The procedure involves removal of endometrial polyps only - use CPT 58558.
• The myomectomy is performed laparoscopically - use CPT 58545 or 58546 based on fibroid size and number.

Coding Guidelines and Billing Instructions

To ensure accurate claim submission for CPT 58561:

• Report 58561 once per operative session, even if multiple fibroids are removed.
• Do not bill separately for dilation and curettage (D&C) or endometrial biopsy - both are included in 58561.
• Hysteroscopic entry and visualization (diagnostic work) are bundled into this code.
• If extensive lysis of adhesions or uterine septum resection is also performed, use modifier 59 to indicate a distinct procedure, only if clearly documented.
• The code carries a 90-day global period under Medicare guidelines.
• Verify payer-specific prior authorization requirements - especially for hospital or ASC settings.

Reimbursement and Coverage Information

The reimbursement amount for CPT 58561 is dependent on the facility setting, in the geographic location and dependent on the type of payer. 

• Average Medicare reimbursement (non-facility): $550–$750
• Facility payment (ASC/hospital): Adjusted per local fee schedule
• Global period: 90 days
• Available as a bundled service: diagnostic hysteroscopy and D&C 

Medical necessity should be backed by relevant ICD-10 codes, e.g.:

• N93.9 – Abnormal uterine and vaginal bleeding, unspecified
• D25.0 – Submucous leiomyoma of uterus
• N97.9 – Female infertility, unspecified
• N85.9 – Noninflammatory disorder of uterus, unspecified

Surgical hysteroscopic myomectomy is often contraindicated if imaging confirmation (such as an ultrasound or sonohysterogram) is required prior to authorization by the many payers. 

Modifier To Use For CPT Code 58561

Use modifiers carefully to clarify the scope or nature of the service:

• Modifier 51 – When performed with other procedures during the same session.
• Modifier 52 – Reduced service (if the myomectomy is incomplete).
• Modifier 59 – Distinct procedural service when a separate hysteroscopic resection, adhesion lysis, or septum correction is performed.
• Modifiers 54, 55, 56 – Used when different providers share preoperative, intraoperative, or postoperative management.
• Modifier 22 – Increased procedural services for unusually complex or prolonged procedures (requires detailed operative report).

Documentation Requirements

Proper documentation is essential for proper reimbursement and audit defense. The following information should be clearly stated in the operative report:

• Clinical indication and preoperative diagnosis.
• Description of fibroids (size, number, and location).
• Technique used for hysteroscopic removal (resectoscope, morcellator, etc.).
• Findings of the uterine cavity and any complications.
• Specimens obtained and sent for pathology.
• Postoperative instructions and recovery plan.

Thorough and specific notes justify the use of CPT 58561 and support the medical necessity for the procedure.

Example Scenarios

Scenario 1 – Submucosal Fibroid Causing Heavy Bleeding

A 42 year old female has menorrhagia. Hysteroscopy shows that there is a fibroid located underneath the uterine lining that is 2.5 cm in size attached to the back of the uterus. Surgeon removes fibroid with a resectoscope. 

→ Report CPT 58561.

Scenario 2 – Infertility from Uterine Cavity Distortion

A patient with primary infertility is found to have two submucous fibroids distorting the uterine cavity. The physician performs hysteroscopic myomectomy to restore normal anatomy.

→ Report CPT 58561 for complete removal of both fibroids.

Scenario 3 – Multiple Fibroids and Incomplete Resection

During hysteroscopic removal of three submucous fibroids, one could not be safely resected due to its depth.

→ Report CPT 58561 with modifier 52 (reduced service) to indicate partial completion.

These examples illustrate accuracy of coding based on proper documentation of the number, size and extent of removal of fibroids. 

Why Choose BillingFreedom for OBGYN Medical Billing

Hysteroscopic surgeries such as myomectomy must be correctly coded and well-documented to ensure adequate reimbursement. BillingFreedom's certified staff is dedicated to OB/GYN medical billing services, giving them the skill and attention to detail required for intricate gynecologic surgical claims. 

We ensure that every claim - from hysteroscopy to advanced laparoscopic procedures - is submitted accurately, supported with the right modifiers, and compliant with payer and CMS rules.

With BillingFreedom’s OBGYN medical billing services, you gain:

• Expert code validation and claim submission.
• Fewer denials and faster reimbursement cycles.
• 100% compliance with the latest AAPC and CMS updates.
• Reliable, transparent revenue cycle support.

For more details about our exceptional OB/GYN billing services, 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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