Summary & Overview
CPT 58356: Endometrial Cryoablation for Abnormal Uterine Bleeding
CPT code 58356 represents endometrial cryoablation (cryotherapy of the uterine lining), typically performed with ultrasound guidance and sometimes combined with suction curettage to treat excessive or abnormal uterine bleeding. The procedure is clinically significant as a minimally invasive option for patients seeking alternatives to hysterectomy or hormonal therapy, affecting utilization and reimbursement policy across outpatient surgical settings nationwide. Key national payers in scope include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find an overview of the clinical context for endometrial cryoablation, typical settings of care, and payer coverage considerations. The publication summarizes benchmarking metrics where available, common billing and coding considerations tied to CPT code 58356, and recent policy or coverage updates that influence prior authorization, medical necessity criteria, and site-of-service determinations. The analysis also highlights areas where data is limited or variable across payers and flags operational impacts for billing teams and revenue cycle managers. Data not available in the input is clearly identified and omitted from specific charts or tables.
Billing Code Overview
CPT code 58356 describes a procedure in which the provider uses extreme cold (cryotherapy) to destroy the endometrial lining of the uterus. Ultrasound guidance is used to place the cryoprobe into all quadrants of the uterine cavity, and the provider may also perform a suction curettage of the uterus as part of the service. The procedure is performed to stop or reduce excessive or abnormal uterine bleeding.
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Service type: Endometrial cryoablation with possible suction curettage
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Typical site of service: Ambulatory surgical center or hospital outpatient department
Clinical & Coding Specifications
Clinical Context
A 38-year-old woman presents to a gynecology clinic with a 12-month history of progressively heavy menstrual bleeding unresponsive to medical therapy (combined oral contraceptives and tranexamic acid). She reports anemia symptoms and has completed childbearing. Pelvic ultrasound shows a normal-sized uterus without focal intracavitary mass. After counseling, the patient elects endometrial ablation by cryotherapy. The clinical workflow includes pre-procedure assessment (history, focused pelvic exam, pregnancy test, informed consent), scheduling in an ambulatory surgery center or hospital outpatient department, preoperative local or monitored anesthesia care, sterile speculum and cervical dilation as needed, ultrasound-guided insertion of the cryoprobe to treat all quadrants of the uterine cavity, optional suction curettage if indicated for sampling or to remove retained products, postprocedure recovery with observation for bleeding or pain, discharge instructions, and follow-up visit to assess symptom improvement and manage anemia if required.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Provider is the usual or primary performer of the service | Use when the billing clinician performed the ablation as the primary surgeon/provider |
22 |