Dive Deep Into Hysteroscopy Coding With This Guide, Part 2
Learn how to report IUD removal and reinsertion. In the first part of this article series, Revenue Cycle Insider examined hysteroscopic procedures that pertained to retained products of conception (RPOC), lysis of adhesions, and uterine septum resections. This final article provides helpful coding information for when you have surgical reports for fibroid removal, impacted intrauterine device (IUD) removals, and endometrial ablations. Read on to walk through real-world coding scenarios to help you code with precision and confidence. Hysteroscopic Removal of Fibroids Means Using 58561 You’ll report 58561 (Hysteroscopy, surgical; with removal of leiomyomata) when a provider performs a hysteroscopic surgical removal of leiomyomata — commonly referred to as submucosal fibroids. This procedure is distinct from polyp removal or endometrial biopsy and is typically performed to treat symptoms such as heavy bleeding, infertility, or pelvic pain due to fibroid presence within the uterine cavity. When coding 58561, it’s important to look for specific terminology in the operative report, such as: Example: The ob-gyn performed multiple procedures, including hysteroscopic fibroid removal, endometrial ablation, and a dilation and curettage (D&C). Since the National Correct Coding Initiative (NCCI) does not bundle 58561 (removal of fibroids) and 58563 (… with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)), you can report these codes together using modifier 51 (Multiple procedures). Do not use modifier 59 (Distinct procedural service), as there is no bundling edit that requires bypassing. Report 58562 for Hysteroscopic Removal of an Impacted IUD You will use 58562 (… with removal of impacted foreign body) to report a hysteroscopic surgical removal of an impacted foreign body, most commonly an impacted IUD embedded in the uterine wall. This code should only be used when documentation clearly supports that the IUD was impacted, not simply retained or with missing strings. To support use of 58562, look in your documentation for terms such as: In a case where a physician removes an IUD hysteroscopically in the operating room (OR) and reinserts a new one, you can report 58562 for the removal if the IUD was embedded. The reinsertion would be reported with 58300 (Insertion of intrauterine device (IUD)). Be sure that your ob-gyn’s documentation clearly states the IUD was impacted — mere use of a hysteroscope for visualization is not enough. If the IUD was not impacted but simply difficult to locate and the ob-gyn performed the hysteroscopy for guidance, you would instead report 58555 (Hysteroscopy, diagnostic (separate procedure)), 58301-51 (Removal of intrauterine device (IUD)), and 58300-51 (IUD insertion). However, some payers may not reimburse for insertion and removal codes together. In such cases, consider using modifier 22 (Increased procedural services) or 59 based on payer guidelines and documentation of increased complexity. In summary, you should reserve 58562 for true surgical removal of an impacted IUD, not for routine or difficult removals without embedding. Proper documentation and modifier use are key to ensuring appropriate reimbursement and avoiding denials. Use 58563 for Hysteroscopic Endometrial Ablation You’ll use 58563 for hysteroscopic surgical procedures involving endometrial ablation, which may include techniques like resection, electrosurgical ablation, or thermoablation. This code is typically used when the physician treats abnormal uterine bleeding that has not responded to more conservative management and is performed to destroy or remove the endometrial lining. When reviewing documentation, look for terminology that supports endometrial ablation, such as: In a case where the ob-gyn performs endometrial ablation along with other hysteroscopic procedures — such as the removal of fibroids (58561) — you may report 58563 together with 58561 using modifier 51. The NCCI edits do not bundle these codes. Example: A patient undergoes hysteroscopic endometrial ablation to address chronic menorrhagia. During the same session, the provider also removes a submucosal fibroid. Report 58563 for the ablation and 58561-51 for the fibroid removal. Do not report additional codes for D&C or polyp removal, as they are included in the ablation procedure. Always confirm payer policies regarding multiple procedures and anesthesia services. Finally, Use 58565 for Hysteroscopic Sterilization With Fallopian Tube Implants You’ll report 58565 (… with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants) when a provider performs hysteroscopic sterilization by placing permanent implants into both fallopian tubes. This code specifically refers to procedures like Essure, where the goal is to induce tubal occlusion and achieve permanent sterilization. To support the use of 58565, look for documentation that includes phrases such as: Important: Code 58565 is intended for bilateral procedures; that is, both tubes must be cannulated and implants placed. If the physician is only able to place an implant in one fallopian tube (for example, if the other is already occluded or inaccessible), report 58565 with modifier 52 (Reduced services) to indicate reduced services. Documentation should clearly explain why the procedure was unilateral. For example, a patient undergoes Essure sterilization. During the procedure, the ob-gyn successfully places implants in both fallopian tubes. Report 58565 without any modifier. However, if only the left tube was treated due to prior occlusion of the right tube, report 58565-52 with an explanation in the operative note. Always confirm that the intent of the procedure was permanent sterilization and not a diagnostic intervention. This code is procedure-specific and should not be used for general hysteroscopies or for tubal evaluation without implant placement. Takeaway As you apply the CPT® codes from the 58558-58565 (Hysteroscopy, surgical …) range, stay alert to the clinical details that support proper code selection. Always confirm whether the procedure was diagnostic or therapeutic, and pay close attention to whether the provider addressed fibroids, polyps, adhesions, or anatomical anomalies like a septum. Look for language that indicates laterality, completeness of the procedure, or use of specialized equipment like a hysteroscope. By aligning your code choice with the provider’s documentation and following current coding guidelines, you ensure accurate claims and support compliant reporting. When you understand both the clinical intent and the procedural scope, you elevate your coding from routine to expert. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
