CPT Code 58565 Surgical Hysteroscopy with Bilateral Fallopian Tube Cannulation and Implant Placement

Hysteroscopic sterilization through bilateral fallopian tube cannulation is a minimally invasive procedure designed for permanent contraception.

A hysteroscope is inserted through the cervix to visualize the uterine cavity, and permanent implants are placed in each fallopian tube to induce scarring and block tubal patency.

While historically associated with the Essure device, the procedure remains relevant for any similar implant-based hysteroscopic sterilization technique. Accurate coding, documentation, and billing are essential to ensure compliance, reimbursement, and proper reporting of procedural intent.

CPT Code 58565 – Description

The official definition of CPT code 58565 is:

“Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants.”

This code describes a therapeutic hysteroscopic procedure performed to achieve permanent sterilization. The procedure involves insertion of a hysteroscope through the cervix into the uterine cavity, cannulation of both fallopian tubes, and placement of permanent implants (such as micro-inserts or coils) to induce scar tissue formation and tubal occlusion. Diagnostic hysteroscopy (CPT 58555) is bundled and not separately reportable when performed during the same session.

The scope of CPT 58565 includes uterine cavity access, bilateral tube cannulation, implant placement, and operative documentation of tubal occlusion.

Scenarios Where CPT Code 58565 Is Applicable

You would bill CPT code 58565 in the following situations:

Permanent Female Sterilization:

When a patient elects for permanent contraception using a minimally invasive hysteroscopic approach. The procedure is appropriate for patients seeking permanent sterilization without undergoing laparoscopic or open tubal ligation.

Example:

A patient requests permanent sterilization. The surgeon performs hysteroscopic bilateral cannulation and implant placement to occlude the fallopian tubes. Operative notes document successful placement and occlusion in both tubes.

Partial Procedures:

If only one fallopian tube can be treated due to prior occlusion or anatomical limitations, the service may be reported with modifier 52 (Reduced Services). Proper documentation is required to justify incomplete bilateral treatment.

Applicable Modifiers for CPT Code 58565

The following modifiers may be used with CPT code 58565 when appropriate:

Modifier 22 – Increased Procedural Services

If the procedure requires additional time, complex cannulation, or difficult anatomy, this modifier may apply with clear operative documentation.

Modifier 52 – Reduced Services

Applicable if only one fallopian tube is treated due to prior occlusion or anatomical constraints.

Modifier 25 – Significant, Separately Identifiable E/M Service

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

All modifier usage must be fully supported by detailed operative documentation.

CPT Code 58565 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58565, follow these key steps:

Justify Medical Necessity:

Document the patient’s request for permanent sterilization and clinical appropriateness of the procedure.

Use Accurate ICD-10 Codes:

Pair CPT 58565 with diagnosis codes indicating desire for sterilization (e.g., Z30.2, Encounter for sterilization).

Confirm Procedural Details:

The operative report should clearly document:

• Hysteroscope insertion and uterine access
• Bilateral fallopian tube cannulation
• Placement of permanent implants
• Confirmation of successful occlusion or reasons for incomplete treatment

Detailed Documentation:

Include any anatomical challenges, operative time, and intraoperative observations to support modifier use and payer compliance.

Reimbursement Considerations:

CPT 58565 reimbursement depends on documentation showing therapeutic intent, bilateral treatment, and technical details. Proper coding ensures payers recognize the minimally invasive sterilization procedure and helps prevent denials.

BillingFreedom – Expert OBGYN Medical Billing Services

BillingFreedom specializes in OBGYN billing for complex procedures like CPT 58565. Our experts stay constantly updated on AMA CPT codes, NCCI edits, and payer-specific rules, ensuring:

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At BillingFreedom, our team meticulously reviews operative notes, verifies CPT and modifier selection, and ensures documentation reflects procedural complexity. Partnering with BillingFreedom’s OBGYN medical billing services in Indiana reduces administrative burden, minimizes claim denials, and enhances financial performance, allowing providers to focus on patient care while maximizing revenue.

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