Suppose you performed a thorough hysteroscopic evaluation, removed an endometrial polyp, and sent the specimen to a laboratory. A clean procedure with a clear outcome. However, a few weeks later, you receive a denial. The reason? A simple mistake in using the procedure code 58558. Sounds frustrating, right?
This scenario happens more often in gynecology practices than you think. What makes CPT code 58558 difficult to bill is its similarity with other related codes. That is why our coding team has put together this complete guide. We will explain what this code is, how to use it effectively in your claims, and discuss some essential guidelines. So, let’s start.
CPT Code 58558 – Description
CPT code 58558 is defined as:
“Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C.”
That’s a lot of technical words, so let’s make them simple. 58558 is used to bill a surgical hysteroscopy in which the physician performs at least one of the following: an endometrial biopsy, a polypectomy (removal of one or more uterine polyps), or a dilation and curettage (D&C). Importantly, the D&C is an optional component. The procedure can be reported with or without it.
As a biller, you might not know what exactly happens during the procedure. Let’s clue you in. The procedure itself begins with the insertion of a thin, lighted camera (the hysteroscope) through the vagina and cervix and into the uterine cavity. The uterus is then distended, typically with saline, to allow direct visualization. Once inside, the physician can:
- Take targeted biopsies of the endometrial lining for pathological examination.
- Identify and remove uterine or endocervical polyps using specialized instruments (polypectomy).
- Perform a D&C to scrape additional endometrial tissue if clinically warranted.
One important thing to note here is that code 58558 is both a diagnostic and therapeutic code. This makes it different from CPT code 58555, which is only used for visualization. Whenever a biopsy, polypectomy, or D&C is performed during the hysteroscopy, you should report 58558, not 58555.
Appropriate Use Cases for CPT Code 58558
Understanding the code is only half the battle. To ensure this code’s proper usage, you must know how it is used in the practical world. To help with this, here are a couple of real-world scenarios in which this code can be used:
Abnormal Uterine Bleeding with Polypectomy
Suppose a 28-year-old female patient comes to a clinic. She complains of heavy menstrual bleeding that has lasted more than seven days over the past three consecutive cycles. She also hints at mid-cycle spotting. She denies any pregnancy or use of anticoagulants. A pelvic ultrasound shows a hyperechoic lesion within the uterine cavity, suggestive of an endometrial polyp. So, the physician schedules her for a surgical hysteroscopy.
In the operating room, the physician introduces the hysteroscope transcervically and spots a 1.5 cm sessile polyp at the fundus. She resects it and sends the specimen for pathology. No D&C is performed. In this scenario, the billing department can use CPT code 58558 to bill the surgical procedure.
Infertility Evaluation with Incidental Polypectomy
A patient with a 14-month history of primary infertility undergoes a sonohysterogram that reveals an endometrial filling defect. The finding is suspicious for an intrauterine polyp, which may be contributing to implantation failure. She is scheduled for a hysteroscopic evaluation and possible polypectomy.
At the time of surgery, a single 1 cm polyp is visualized on the posterior wall and removed. The rest of the endometrial cavity appears normal. No D&C is performed. Similar to the first scenario, CPT code 58558 can be used here to bill the procedure.
Modifiers to Append with CPT Code 58558
Here are some modifiers that are frequently used with CPT code 58558:
| Modifier | Description | Application |
|---|---|---|
| 22 | Increased Procedural Services | When the procedure was significantly more complex than usual (e.g., extensive adhesions, distorted anatomy, or difficult cervical dilation) and required extra surgical time and effort. |
| 52 | Reduced Services | When the procedure was started, but only partially completed. |
| 53 | Discontinued Procedure | When the procedure was terminated after initiation and anesthesia administration due to patient safety concerns or intraoperative complications. |
Reimbursement Guidelines for CPT Code 58558
Let’s now look at some additional guidelines that you need to know:
Know the Global Period
CPT code 58558 has a 0-day global period. This means that pre-operative and post-operative care on other days is not included in the payment.
You may bill those visits separately.
Provide Detailed Documentation
Submitting detailed documentation for the procedure and the patient’s medical record is vital if you want to get fully reimbursed. Without it, your claims will be rejected. The following details are essential to be provided with 58558 claims:
- Pre- and post-operative diagnoses with supporting clinical evidence.
- A clear statement that a hysteroscope was introduced and used for direct uterine visualization.
- Explicit description of whether an endometrial biopsy, polypectomy, and/or D&C was performed.
- Size, number, and anatomical location of any polyps or lesions removed.
- Method of biopsy or tissue removal.
- Type of anesthesia used and the setting of the procedure.
- Any intraoperative findings or complications.
Pair with Relevant ICD-10 Diagnosis Codes
Every CPT claim must be paired with an ICD-10 diagnosis code that justifies the medical necessity of the procedure. The following are some diagnosis codes that are frequently used with CPT code 58558:
- D25.0: Submucous leiomyoma of uterus
- N84.0: Polyp of the corpus uteri
- N85.00: Endometrial hyperplasia, unspecified
- N85.01: Benign endometrial hyperplasia
- N93.8: Other specified abnormal uterine and vaginal bleeding
- N95.0: Postmenopausal bleeding
- N97.2: Female infertility of uterine origin
Check the Reimbursement Rate
According to the 2026 Physician Fee Schedule, Medicare currently pays $1,269.90 for CPT code 58558 in non-facility settings, and $204.41 in facility settings.
However, this rate varies significantly for each Medicare Administrative Contractor (MAC) locality. You can check the exact amount for your MAC via the PFS Lookup Tool.
Final Thoughts
Let’s wrap up everything we have discussed.
- CPT code 58558 is a gynecology billing code. It is used to bill a surgical hysteroscopy, in
- For proper reimbursement, you must append the appropriate modifiers to the code when necessary and provide detailed documentation to support your claim.
- If your practice is seeing frequent denials for 58558 or other hysteroscopy codes, acquiring specialized OBGYN billing services from companies like NeuraBill can help you reduce claim rejections. which a biopsy, polypectomy, or dilation and curettage can be performed.
- It is both a diagnostic and therapeutic code.
