CPT Code 58580 Transcervical Radiofrequency Ablation of Uterine Fibroids

CPT 58580 is used for a minimally invasive procedure to treat uterine fibroids without removing the uterus. In this procedure, the doctor uses a device inserted through the cervix to deliver radiofrequency energy that shrinks fibroids. The procedure is done under real-time ultrasound guidance, which is already included in the code, meaning you should not bill separately for it.

It is commonly associated with radiofrequency systems such as Sonata® and is an important coding consideration for gynecology and women’s health practices.

CPT Code 58580 – Description

The official definition of CPT code 58580 is:

“Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency.”

This code describes a minimally invasive procedure in which uterine fibroids are destroyed via radiofrequency energy delivered transcervically. The procedure includes real-time intraoperative ultrasound guidance and monitoring. CPT 58580 is specifically for fibroid ablation while preserving the uterus. No additional code should be billed separately for ultrasound guidance performed during the same session.

Scenarios Where CPT Code 58580 Is Applicable

You would bill CPT code 58580 in the following situations:

Symptomatic Fibroids:

When a patient has uterine fibroids causing abnormal uterine bleeding, pelvic pain, or reproductive issues, and the clinician performs transcervical RFA.

Example:

A 38-year-old patient with multiple intramural fibroids undergoes transcervical radiofrequency ablation using intraoperative ultrasound. Operative notes document fibroid number, size, location, and successful ablation, with the uterus preserved.

Fibroid Location or Size Requiring Guidance:

If fibroids are difficult to localize or require precise targeting, intraoperative ultrasound guidance ensures safe and effective ablation. This guidance is included in the CPT 58580 code.

Applicable Modifiers for CPT Code 58580

Modifier 22 – Increased Procedural Services

Use if the procedure required additional effort due to technical complexity, such as multiple fibroids, unusual uterine anatomy, or extended operative time. Documentation must clearly justify the increased service.

No other modifiers are routinely required for this code unless payer-specific rules indicate otherwise.

CPT Code 58580 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58580, follow these key steps:

Justify Medical Necessity:

Document the clinical indication, including fibroid symptoms, prior failed therapies, and rationale for RFA over alternative treatments.

Use Accurate ICD-10 Codes:

Pair CPT 58580 with appropriate diagnosis codes, such as:

• D25.x (Leiomyoma of uterus)
• N92.x (Abnormal uterine bleeding, if clinically justified)

Confirm Procedural Details:

The operative report should clearly document:

• Transcervical approach
• Number, size, and location of fibroids ablated
• Use of radiofrequency energy
• Intraoperative ultrasound guidance and monitoring
• Uterus preservation

Detailed Documentation:

Include any complications, technical challenges, or additional interventions needed to support coding and reimbursement.

Reimbursement Considerations:

CPT 58580 is a single bundled code that includes ultrasound guidance. Accurate coding ensures payers recognize the minimally invasive fibroid treatment and allows appropriate reimbursement while differentiating it from other hysteroscopic or laparoscopic procedures.

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