Identify the Correct Fibroid Resection Code
Question: A gynecologist performs saline infusion sonohysterography on a 42-year-old patient who presented with heavy menstrual bleeding, infertility, and recurrent pregnancy loss. The physician found a 2.4 cm intracavitary submucosal leiomyoma and distortion of the endometrial cavity during the imaging exam. The gynecologist then performed a hysteroscopic removal of the submucosal fibroid in the ambulatory surgical center (ASC). What CPT® code best describes the hysteroscopic resection of the submucosal fibroid? Pennsylvania Subscriber Answer: CPT® code 58561 (Hysteroscopy, surgical; with removal of leiomyomata) best represents the hysteroscopic resection of the submucosal fibroid. This code is the most accurate because the gynecologist removed the fibroid using a hysteroscope. Coders might be tempted to use 58558 (… with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C) to report the procedure, but that is incorrect because the physician removed a leiomyoma — they didn’t just perform a biopsy or polypectomy. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
