CPT Code 58563 Hysteroscopy with Endometrial Ablation

Accurate procedural coding is vital for OBGYN practices to ensure proper reimbursement, minimize denials, and maintain compliance. CPT 58563 represents a hysteroscopic endometrial ablation, a minimally invasive surgical procedure performed to treat abnormal uterine bleeding by destroying (ablating) the endometrial lining.

Because multiple ablation techniques and devices exist, it’s essential that providers clearly document the method used and the purpose of the procedure. Understanding when to use CPT 58563 and how to bill it correctly helps secure timely payment and prevent payer disputes.

CPT Code 58563 – Description of the Procedure

Official CPT Definition: “Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical, thermal, or cryoablation).”

This code describes a therapeutic hysteroscopic procedure in which the physician inserts a hysteroscope through the cervix to visualize the uterine cavity. Using electrosurgical, laser, thermal, or cryo-based techniques, the endometrial lining is destroyed to control or eliminate abnormal uterine bleeding.

Common techniques include rollerball ablation, resectoscopic resection, or global endometrial ablation systems. The objective is to reduce or stop menstrual bleeding, avoiding the need for hysterectomy in many cases.

When to Use CPT 58563

CPT 58563 is used when the physician performs an endometrial ablation under direct hysteroscopic visualization for therapeutic purposes.

Common clinical indications include:

• Abnormal uterine bleeding (AUB) is unresponsive to medication or hormonal therapy.
• Menorrhagia (heavy menstrual bleeding) in patients not desiring future fertility.
• Dysfunctional uterine bleeding due to hormonal imbalance or perimenopause.
• Endometrial hyperplasia without atypia is treated with ablation as a conservative approach.

Do not use CPT 58563 when:

• The ablation is performed without hysteroscopic guidance - use CPT 58353 (thermal ablation without hysteroscopy).
• The procedure is diagnostic only - use CPT 58555.
• Other therapeutic hysteroscopic interventions are performed (e.g., myomectomy or adhesiolysis), use CPT 58561 or 58562 as appropriate.

Coding Guidelines and Billing Rules

Accurate billing of CPT 58563 requires adherence to bundling, modifier, and documentation rules:

• Single reporting: Bill 58563 once per operative session, regardless of the technique used.
• Bundled services: Includes diagnostic hysteroscopy and dilation & curettage (D&C) performed as part of the same session.
• Global period: 90 days.
• Prior authorization: May be required by some payers, especially when performed for abnormal bleeding.
• Site of service: Commonly performed in a hospital, outpatient, or ambulatory surgical center (ASC).
• Device-specific reporting: The CPT code remains 58563 regardless of ablation device type (e.g., NovaSure, HydroThermAblator, ThermaChoice).

If multiple procedures are performed during the same session (e.g., myomectomy with ablation), append modifier 59 to indicate separate, distinct services - supported by clear documentation.

Reimbursement and Coverage Information

Reimbursement for CPT 58563 varies by payer and location, but typically includes the cost of equipment and procedural expertise.

Approximate Medicare Payment Ranges:

• Physician Fee (non-facility): $500–$700
• ASC Facility Payment: $900–$1,300
• Hospital Outpatient Payment: $1,200–$1,500
• Global period: 90 days

Common ICD-10 codes supporting medical necessity:

• N92.0 – Excessive and frequent menstruation with regular cycle
• N92.1 – Excessive and frequent menstruation with irregular cycle
• N92.4 – Excessive bleeding in the premenopausal period
• N93.9 – Abnormal uterine and vaginal bleeding, unspecified
• N85.9 – Noninflammatory disorder of uterus, unspecified

Ensure pre-procedure imaging or endometrial evaluation is documented to confirm structural normalcy and rule out malignancy before ablation.

Modifier Use

Appropriate modifier use clarifies the scope and circumstances of care:

• Modifier 51 – Multiple procedures performed during the same operative session.
• Modifier 52 – Reduced services (e.g., incomplete ablation due to patient intolerance).
• Modifier 59 – Distinct procedural service when combined with another hysteroscopic procedure.
• Modifiers 54, 55, 56 – Used when different providers manage preoperative, intraoperative, or postoperative care.
• Modifier 22 – Increased procedural service (for complex anatomy or excessive bleeding).

Documentation Requirements

Complete operative documentation supports CPT 58563 coding and payer approval. Key elements include:

• Indication for surgery (AUB, menorrhagia, etc.)
• Preoperative findings and prior conservative treatments.
• Description of the ablation technique used (device type and method).
• Extent of ablation and verification of cavity integrity post-procedure.
• Complications, if any, and the immediate postoperative plan.
• Pathology report if tissue samples were sent for evaluation.

Detailed, well-structured notes are essential for payer audits and to support medical necessity for endometrial ablation.

Example Scenarios

Scenario 1 – Menorrhagia Resistant to Medical Therapy

A 44-year-old patient with heavy, irregular menses despite hormonal therapy undergoes hysteroscopic ablation using the NovaSure system. Visualization confirms complete ablation of the endometrial surface.

→ Report CPT 58563.

Scenario 2 – Endometrial Ablation After Failed D&C

A patient with persistent dysfunctional uterine bleeding following prior D&C undergoes resectoscopic ablation under direct hysteroscopic view.

→ Report CPT 58563.

Scenario 3 – Combined Ablation and Polyp Removal

During hysteroscopy, a small endometrial polyp is removed before thermal ablation is performed.

→ Report CPT 58563 and 58558 with modifier 59 for distinct procedural services.

These examples highlight how clinical context and complete documentation guide accurate CPT selection and modifier use.

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