CPT Code 58562 Hysteroscopy, Surgical; with Removal of Myoma(s)

Accurate coding of hysteroscopic procedures is essential for correct reimbursement and audit readiness. CPT 58562 represents a hysteroscopic surgical procedure involving the removal of intrauterine adhesions (synechiae).

This therapeutic code is commonly used for cases of Asherman’s syndrome or uterine scarring that cause infertility or abnormal bleeding.

Because this procedure may appear similar to other hysteroscopic interventions such as myomectomy or polypectomy, it’s important to understand the documentation and coding distinctions that define CPT 58562.

CPT Code 58562 – Description of the Procedure

Official CPT Definition: “Hysteroscopy, surgical; with lysis of intrauterine adhesions (synechiae).”

In this minimally invasive procedure, the surgeon inserts a hysteroscope through the cervix into the uterine cavity. Using mechanical instruments, scissors, or electrosurgical energy, the physician carefully cuts and removes fibrous scar tissue (adhesions) that may partially or completely block the uterine cavity.

The goal is to restore the normal shape and function of the uterine cavity, improving fertility potential and resolving menstrual abnormalities. This is a therapeutic, not diagnostic, procedure, meaning it treats a known intrauterine problem identified through prior imaging or hysteroscopic evaluation.

When to Use CPT 58562

You should report CPT 58562 when hysteroscopic surgery is performed for the removal or dissection of adhesions that prevent normal uterine function.

Common clinical indications include:

• Asherman’s syndrome (intrauterine adhesions following curettage or infection)
• Amenorrhea or hypomenorrhea caused by uterine scarring
• Infertility due to intrauterine adhesions
• Recurrent pregnancy loss related to fibrotic uterine cavity changes
• Post-surgical adhesions following cesarean section or uterine procedures

Do not report CPT 58562 when:

• Only diagnostic hysteroscopy is performed; use CPT 58555.
• If polyps or fibroids are removed, use CPT 58558 or CPT 58561, respectively.
• The adhesiolysis is performed laparoscopically; use the appropriate laparoscopic code instead.

Coding Guidelines and Billing Rules

To code CPT 58562 correctly and avoid denials, follow these key points:

• Report 58562 only once per surgical session, regardless of the number of adhesions removed.
• Do not bill separately for diagnostic hysteroscopy or D&C performed as part of the same procedure; they are bundled under 58562.
• If other distinct hysteroscopic procedures (e.g., myomectomy or septum resection) are performed in the same session, append modifier 59 to indicate a separate, non-overlapping procedure.
• Global period: 90 days.
• Site of service: Usually performed in a hospital outpatient department or ambulatory surgical center (ASC).
• Prior authorization is often required, especially when the indication is infertility or recurrent miscarriage.

Reimbursement and Coverage Information

Reimbursement for CPT 58562 depends on payer policies and geographic location.

Typical ranges include:

• Average Medicare payment (non-facility): $500–$700
• ASC or hospital payment: $900–$1,200 (average)
• Global period: 90 days

Common ICD-10 codes that support medical necessity:

• N85.6 – Intrauterine synechiae
• N97.9 – Female infertility, unspecified
• N91.1 – Secondary amenorrhea
• N93.9 – Abnormal uterine bleeding, unspecified

Coverage for hysteroscopic adhesiolysis generally requires documentation showing that conservative or non-surgical treatments were unsuccessful and that the adhesions were confirmed by imaging or hysteroscopy before surgery.

Appropriate Modifier Use

Modifiers clarify the scope of service or differentiate between multiple procedures:

• Modifier 51 – When performed with other surgical procedures during the same session.
• Modifier 52 – Reduced services (e.g., if adhesiolysis is only partially completed).
• Modifier 59 – Distinct procedural service if combined with other unrelated hysteroscopic procedures.
• Modifiers 54, 55, 56 – When different providers manage surgical, postoperative, or preoperative care separately.
• Modifier 22 – For unusually difficult or prolonged adhesiolysis (must be justified by operative report).

Documentation Requirements

Accurate operative notes are essential for supporting CPT 58562 billing. A compliant record should include:

• Clinical indication and preoperative diagnosis.
• Description of the adhesions (extent, thickness, and location).
• Surgical approach and technique used for lysis (mechanical or electrosurgical).
• Confirmation that the uterine cavity was restored or improved.
• Any complications or additional findings
• Pathology report confirmation, if tissue was sent for analysis.

Complete and precise documentation helps justify the procedure, prevents denials, and demonstrates medical necessity.

Example Scenarios

Scenario 1 – Infertility Due to Asherman’s Syndrome

A 34-year-old woman presents with infertility and a history of D&C for miscarriage. Hysteroscopy reveals extensive intrauterine adhesions, which are carefully lysed to restore cavity patency.

→ Report CPT 58562.

Scenario 2 – Amenorrhea from Postpartum Scarring

A patient experiences secondary amenorrhea after postpartum curettage. Hysteroscopy identifies adhesions near the fundus and left cornual area, which are removed using hysteroscopic scissors.

→ Report CPT 58562.

Scenario 3 – Combined Procedure with Fibroid Removal

During hysteroscopic adhesiolysis, a small submucosal fibroid is also removed.

→ Report CPT 58562 and 58561 with modifier 59 to indicate distinct services.

These scenarios illustrate how correct coding depends on documenting the scope, findings, and exact nature of each intrauterine intervention.

Why Choose BillingFreedom for OBGYN Billing

Procedures like hysteroscopic adhesiolysis require detailed documentation, accurate coding, and vigilant compliance monitoring to secure full reimbursement. At BillingFreedom, our certified team specializes in OBGYN medical billing services, ensuring clean claim submission, accurate modifier use, and adherence to payer and CMS guidelines.

With BillingFreedom, you can:

• Prevent denials related to incomplete hysteroscopy documentation.
• Streamline reimbursement for infertility-related surgical cases.
• Stay fully compliant with coding updates and payer policies.
• Focus on patient care while we manage your revenue cycle end-to-end.

For more details about our exceptional OB/GYN medical 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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