Accurate coding is critical in women’s healthcare especially when it comes to surgical gynecologic procedures. One code that often raises questions among providers and billing professionals is CPT code 58558. Whether you are an obstetrician-gynecologist (OBGYN) a gynecologist, or part of a medical billing team, understanding the correct application of this code is essential for compliance and proper reimbursement.
This comprehensive guide explains the 58558 CPT description, when to use it, documentation requirements, reimbursement considerations and common billing mistakes to avoid.
What Is CPT Code 58558?
CPT code 58558 refers to:
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without dilation and curettage (D&C).
In simple terms, cpt 58558 is used when a provider performs a hysteroscopic procedure to remove endometrial polyps and/or take a biopsy sample from inside the uterus.
58558 CPT Description Explained
The official 58558 CPT description includes several key components:
- Hysteroscopy (surgical) – A minimally invasive procedure using a hysteroscope inserted through the cervix to visualize the uterine cavity.
- Endometrial sampling or biopsy – Removal of tissue from the lining of the uterus.
- Polypectomy – Removal of uterine polyps.
- With or without dilation and curettage (D&C) – Dilation of the cervix and scraping of the uterine lining may or may not be performed.
Understanding the full 58558 CPT code description helps ensure that all elements of the procedure meet coding criteria.
When Should CPT 58558 Be Used?
An obstetrician-gynecologist (OBGYN) or gynecologist may use CPT 58558 when:
- A patient presents with abnormal uterine bleeding
- Imaging reveals suspected endometrial polyps
- Endometrial biopsy is clinically indicated
- Hysteroscopic removal of tissue is required
This code applies specifically to surgical hysteroscopy involving tissue removal or sampling—not diagnostic hysteroscopy alone.
Difference Between Diagnostic and Surgical Hysteroscopy
It’s important to distinguish between diagnostic hysteroscopy and procedures that qualify for 58558 CPT code billing.
- Diagnostic hysteroscopy (visual inspection only) is billed separately under a different code.
- Surgical hysteroscopy with biopsy or polypectomy qualifies for cpt 58558.
If tissue removal or biopsy occurs, the procedure becomes therapeutic rather than purely diagnostic.
Clinical Indications for CPT Code 58558
Common medical conditions leading to this procedure include:
- Endometrial polyps
- Abnormal uterine bleeding (AUB)
- Postmenopausal bleeding
- Thickened endometrium
- Infertility evaluation
- Suspected endometrial pathology
Proper documentation of medical necessity is crucial for reimbursement approval.
Documentation Requirements
To support billing for 58558 cpt code, medical records should clearly include:
- Preoperative diagnosis
- Indication for hysteroscopy
- Description of hysteroscopic findings
- Details of biopsy or polypectomy
- Confirmation of tissue removal
- Any dilation and curettage performed
- Postoperative diagnosis
Incomplete documentation can lead to claim denials or audit risks.
Reimbursement Considerations
Reimbursement for cpt 58558 depends on:
- Payer guidelines
- Facility vs. non-facility setting
- Geographic location
- Contract agreements
Medicare and commercial payers typically reimburse this code when medical necessity is well-documented.
Billing teams should verify:
- Global surgical period
- Modifier requirements (if applicable)
- Bundling rules under NCCI edits
Common Billing Errors to Avoid
Even experienced coders may make mistakes when billing 58558 cpt code. Common issues include:
1. Reporting Diagnostic and Surgical Codes Together
If biopsy or polypectomy is performed, do not bill a separate diagnostic hysteroscopy code.
2. Lack of Documentation
Failure to clearly document tissue removal can result in denial.
3. Incorrect Modifier Usage
Modifiers should only be applied when medically appropriate and supported by documentation.
4. Confusing 58558 with Similar Codes
There are other hysteroscopy CPT codes for myomectomy or more extensive procedures. Ensure the performed service matches the 58558 cpt description exactly.
Role of the Gynecologist in This Procedure
A gynecologist or obstetrician-gynecologist (OBGYN) performs hysteroscopic procedures to diagnose and treat uterine conditions. These specialists are trained in minimally invasive surgical techniques that allow visualization and treatment within the uterine cavity.
Using cpt code 58558 accurately reflects the complexity and clinical value of this procedure.
Global Period and Postoperative Care
CPT 58558 typically carries a global surgical period. During this time:
- Routine postoperative visits are included in the reimbursement.
- Additional unrelated procedures may require modifiers.
Understanding global surgery rules helps prevent unintentional underbilling or overbilling.
Frequently Asked Questions
What is CPT code 58558?
CPT code 58558 describes surgical hysteroscopy with endometrial biopsy and/or polypectomy, with or without dilation and curettage.
What is the 58558 CPT description?
It includes hysteroscopic removal of uterine polyps or sampling of endometrial tissue.
Can a gynecologist bill CPT 58558?
Yes, a licensed gynecologist or obstetrician-gynecologist (OBGYN) can report this code when performing the qualifying procedure.
Is dilation and curettage required for CPT 58558?
No. The procedure may include D&C, but it is not mandatory for reporting the code.
How is CPT 58558 different from diagnostic hysteroscopy?
Diagnostic hysteroscopy involves visualization only, while CPT 58558 includes surgical intervention such as biopsy or polypectomy.
Final Thoughts
Understanding CPT code 58558 is essential for accurate coding in women’s healthcare. The 58558 CPT code description specifically applies to surgical hysteroscopy with tissue sampling or polyp removal, with or without dilation and curettage.
For every obstetrician-gynecologist (OBGYN) and gynecologist, proper documentation and correct coding ensure compliance, reduce denials, and support appropriate reimbursement.
By mastering the details of cpt 58558, healthcare providers and billing professionals can maintain accurate revenue cycle management while delivering high-quality patient care.
