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CPT 58558: Hysteroscopic Endometrial Biopsy and Polypectomy

CPT code 58558 covers hysteroscopic evaluation with endometrial biopsy and/or polypectomy, a commonly used outpatient gynecologic procedure to diagnose and treat intrauterine pathology. Nationally, this code matters because it captures both diagnostic sampling and minor operative work performed via hysteroscopy, and it informs payment, quality reporting, and utilization tracking for women’s health services. Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will find a concise review of the clinical context for CPT code 58558, typical sites of service, and the types of specimens submitted for pathological analysis. The publication summarizes payer coverage patterns and common billing practices, presents benchmark metrics for utilization and site-of-service distribution, and highlights policy considerations that affect coding and claims adjudication for hysteroscopic endometrial biopsies and polypectomies. The report is intended to support coding accuracy, claims preparation, and payer-provider communication in outpatient gynecologic care.

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Billing Code Overview

CPT code 58558 describes a hysteroscopic procedure in which the provider biopsies the endometrial lining, removes uterine polyps, or performs both interventions through a hysteroscope. The description notes that a dilation and curettage (D&C) may or may not be performed as part of the procedure. All tissue samples obtained are sent to the laboratory for pathological analysis.

Service type: Diagnostic and operative hysteroscopy with endometrial biopsy and/or polypectomy
Typical site of service: Ambulatory surgical center or hospital outpatient department (outpatient procedure using hysteroscopy)

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CPT 58558: Hysteroscopic Endometrial Biopsy and Polypectomy

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Billing Code Overview

Service type: Diagnostic and operative hysteroscopy with endometrial biopsy and/or polypectomy
Typical site of service: Ambulatory surgical center or hospital outpatient department (outpatient procedure using hysteroscopy)

Clinical & Coding Specifications

Clinical Context

A 42-year-old woman presents to the gynecology clinic with several months of abnormal uterine bleeding and intermenstrual spotting. Prior evaluation includes pelvic ultrasound showing an endometrial polyp or focal thickening of the endometrium. The patient is scheduled for operative hysteroscopy with targeted endometrial biopsy and polypectomy under monitored anesthesia care. The provider performs hysteroscopic inspection of the uterine cavity, resects identified polyps and obtains directed endometrial biopsies; specimens are sent to pathology. A dilation and curettage (D&C) may be performed based on intraoperative findings. The typical workflow includes preoperative consent and assessment in the clinic, scheduling to an ambulatory surgery center or hospital outpatient department, preoperative anesthesia assessment, procedure documentation including findings and specimens sent to the laboratory, and postoperative instructions with pathology follow-up.

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service on same day	Use when a separate E/M visit is performed on the same day as the procedure for a distinct problem.
`51`	Multiple procedures	Use when more than one distinct procedure is performed and multiple-procedure payment rules apply.
`52`	Reduced services	Use when the procedure is partially reduced or discontinued.
`53`	Discontinued procedure	Use when the procedure is started but halted for patient-related or medical reasons.
`59`	Distinct procedural service	Use to indicate a separate, distinct procedure or service not normally reported together.
`76`	Repeat procedure by same physician	Use when the same physician repeats the procedure later the same day.
`77`	Repeat procedure by another physician	Use when a different physician repeats the procedure the same day.
`78`	Unplanned return to OR by same physician following initial procedure	Use if the patient returns to the operating room for a related procedure during the postoperative period.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use for an unrelated procedure during the global period.
`22`	Increased procedural services	Use when work or complexity is substantially greater than typical for the procedure.
`52`	Reduced services	Use when fewer services are performed than described by the full code (listed above for emphasis).
`24`	Unrelated E/M during postoperative period	Use for an unrelated E/M visit during the global period.
`26`	Professional component	Use when billing only the professional portion of a service that has professional and technical components.
`TC`	Technical component	Use when billing only the technical portion of a service or equipment-dependent procedure.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Obstetrics & Gynecology	Primary specialty performing hysteroscopy, endometrial biopsy, and polypectomy.
`207QA0000X`	Gynecologic Oncology	Performs diagnostic or therapeutic hysteroscopy when malignancy is suspected.
`2083P0105X`	Family Medicine	May perform office-based endometrial sampling or hysteroscopic procedures in some practices.
`363L00000X`	Ambulatory Surgery Facility	Facility taxonomy that commonly bills the technical component/ facility charges for the procedure.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N92.0`	Excessive and frequent menstruation with regular cycle	Common indication for endometrial sampling and hysteroscopic evaluation.
`N93.9`	Abnormal uterine and vaginal bleeding, unspecified	Frequent presenting symptom prompting hysteroscopy and biopsy.
`N84.0`	Polyp of corpus uteri	Direct indication for hysteroscopic polypectomy.
`N85.0`	Endometrial hyperplasia	Suspicion based on imaging or bleeding leading to biopsy for diagnosis.
`N86`	Erosion and ectropion of cervix	May be evaluated concurrently; sometimes requires biopsy during hysteroscopy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`58558`	Hysteroscopy, diagnostic and/or operative; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C	Primary procedure: hysteroscopic inspection with endometrial biopsy and/or polypectomy; specimens sent to pathology.
`58100`	Endometrial sampling (biopsy) without hysteroscopy	Alternative to hysteroscopic-directed biopsy when performed blind in the office; may be performed when hysteroscopy is not indicated.
`57501`	Endometrial curettage, diagnostic and/or therapeutic (separate procedure)	D&C performed in addition to or separate from hysteroscopic sampling for more extensive tissue removal.
`58558`	Hysteroscopy with operative procedures (same code repeated as primary)	Indicates the primary operative hysteroscopic procedure; retained here to show the principal workflow code.
`88305`	Level IV surgical pathology, gross and microscopic examination	Typical pathology CPT code used for histologic evaluation of endometrial or polyp specimens obtained during the procedure.

CPT 58541: Laparoscopic Subtotal Hysterectomy, Uterus Removed; Cervix Preserved

CPT-58542-LAPAROSCOPIC-SUBTOTAL-HYSTERECTOMY-SUPRACERVICAL

CPT 58542: Laparoscopic Subtotal (Supracervical) Hysterectomy

CPT-58543-LAPAROSCOPIC-SUBTOTAL-HYSTERECTOMY-ENLARGED-UTERUS

CPT 58543: Laparoscopic Subtotal Hysterectomy for Enlarged Uterus (>250 g)

CPT-58544-LAPAROSCOPIC-SUPRACERVICAL-HYSTERECTOMY-ENLARGED-UTERUS

CPT 58544: Laparoscopic Supracervical Hysterectomy for Enlarged Uterus

CPT-58545-LAPAROSCOPIC-MYOMECTOMY-1-TO-4-FIBROIDS-UP-TO-250G

CPT 58545: Laparoscopic Myomectomy, 1–4 Fibroids (≤250 g)

CPT-58546-LAPAROSCOPIC-MYOMECTOMY-MULTIPLE-OR-MASSIVE-FIBROIDS

CPT 58546: Laparoscopic Myomectomy for Multiple or Large Fibroids

CPT-58548-LAPAROSCOPIC-RADICAL-HYSTERECTOMY-BSO-PELVIC-LYMPHADENECTOMY

CPT 58548: Laparoscopic Radical Hysterectomy with BSO and Pelvic Lymphadenectomy

CPT-58550-LAPAROSCOPIC-ASSISTED-VAGINAL-HYSTERECTOMY-NORMAL-UTERUS

CPT 58550: Laparoscopic-Assisted Vaginal Hysterectomy, Normal-Size Uterus

CPT-58552-VAGINAL-HYSTERECTOMY-WITH-LAPAROSCOPIC-ASSISTANCE

CPT 58552: Vaginal Hysterectomy With Laparoscopic Assistance

CPT-58553-LAPAROSCOPICALLY-ASSISTED-VAGINAL-HYSTERECTOMY-ENLARGED-UTERUS

CPT 58553: Laparoscopically Assisted Vaginal Hysterectomy for Enlarged Uterus

Showing 1–10 of 25

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service on same day	Use when a separate E/M visit is performed on the same day as the procedure for a distinct problem.
`51`	Multiple procedures	Use when more than one distinct procedure is performed and multiple-procedure payment rules apply.
`52`	Reduced services	Use when the procedure is partially reduced or discontinued.
`53`	Discontinued procedure	Use when the procedure is started but halted for patient-related or medical reasons.
`59`	Distinct procedural service	Use to indicate a separate, distinct procedure or service not normally reported together.
`76`	Repeat procedure by same physician	Use when the same physician repeats the procedure later the same day.
`77`	Repeat procedure by another physician	Use when a different physician repeats the procedure the same day.
`78`	Unplanned return to OR by same physician following initial procedure	Use if the patient returns to the operating room for a related procedure during the postoperative period.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use for an unrelated procedure during the global period.
`22`	Increased procedural services	Use when work or complexity is substantially greater than typical for the procedure.
`52`	Reduced services	Use when fewer services are performed than described by the full code (listed above for emphasis).
`24`	Unrelated E/M during postoperative period	Use for an unrelated E/M visit during the global period.
`26`	Professional component	Use when billing only the professional portion of a service that has professional and technical components.
`TC`	Technical component	Use when billing only the technical portion of a service or equipment-dependent procedure.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Obstetrics & Gynecology	Primary specialty performing hysteroscopy, endometrial biopsy, and polypectomy.
`207QA0000X`	Gynecologic Oncology	Performs diagnostic or therapeutic hysteroscopy when malignancy is suspected.
`2083P0105X`	Family Medicine	May perform office-based endometrial sampling or hysteroscopic procedures in some practices.
`363L00000X`	Ambulatory Surgery Facility	Facility taxonomy that commonly bills the technical component/ facility charges for the procedure.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N92.0`	Excessive and frequent menstruation with regular cycle	Common indication for endometrial sampling and hysteroscopic evaluation.
`N93.9`	Abnormal uterine and vaginal bleeding, unspecified	Frequent presenting symptom prompting hysteroscopy and biopsy.
`N84.0`	Polyp of corpus uteri	Direct indication for hysteroscopic polypectomy.
`N85.0`	Endometrial hyperplasia	Suspicion based on imaging or bleeding leading to biopsy for diagnosis.
`N86`	Erosion and ectropion of cervix	May be evaluated concurrently; sometimes requires biopsy during hysteroscopy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`58558`	Hysteroscopy, diagnostic and/or operative; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C	Primary procedure: hysteroscopic inspection with endometrial biopsy and/or polypectomy; specimens sent to pathology.
`58100`	Endometrial sampling (biopsy) without hysteroscopy	Alternative to hysteroscopic-directed biopsy when performed blind in the office; may be performed when hysteroscopy is not indicated.
`57501`	Endometrial curettage, diagnostic and/or therapeutic (separate procedure)	D&C performed in addition to or separate from hysteroscopic sampling for more extensive tissue removal.
`58558`	Hysteroscopy with operative procedures (same code repeated as primary)	Indicates the primary operative hysteroscopic procedure; retained here to show the principal workflow code.
`88305`	Level IV surgical pathology, gross and microscopic examination	Typical pathology CPT code used for histologic evaluation of endometrial or polyp specimens obtained during the procedure.

CPT 58541: Laparoscopic Subtotal Hysterectomy, Uterus Removed; Cervix Preserved

CPT-58542-LAPAROSCOPIC-SUBTOTAL-HYSTERECTOMY-SUPRACERVICAL

CPT 58542: Laparoscopic Subtotal (Supracervical) Hysterectomy

CPT-58543-LAPAROSCOPIC-SUBTOTAL-HYSTERECTOMY-ENLARGED-UTERUS

CPT 58543: Laparoscopic Subtotal Hysterectomy for Enlarged Uterus (>250 g)

CPT-58544-LAPAROSCOPIC-SUPRACERVICAL-HYSTERECTOMY-ENLARGED-UTERUS

CPT 58544: Laparoscopic Supracervical Hysterectomy for Enlarged Uterus

CPT-58545-LAPAROSCOPIC-MYOMECTOMY-1-TO-4-FIBROIDS-UP-TO-250G

CPT 58545: Laparoscopic Myomectomy, 1–4 Fibroids (≤250 g)

CPT-58546-LAPAROSCOPIC-MYOMECTOMY-MULTIPLE-OR-MASSIVE-FIBROIDS

CPT 58546: Laparoscopic Myomectomy for Multiple or Large Fibroids

CPT-58548-LAPAROSCOPIC-RADICAL-HYSTERECTOMY-BSO-PELVIC-LYMPHADENECTOMY

CPT 58548: Laparoscopic Radical Hysterectomy with BSO and Pelvic Lymphadenectomy

CPT-58550-LAPAROSCOPIC-ASSISTED-VAGINAL-HYSTERECTOMY-NORMAL-UTERUS

CPT 58550: Laparoscopic-Assisted Vaginal Hysterectomy, Normal-Size Uterus

CPT-58552-VAGINAL-HYSTERECTOMY-WITH-LAPAROSCOPIC-ASSISTANCE

CPT 58552: Vaginal Hysterectomy With Laparoscopic Assistance

CPT-58553-LAPAROSCOPICALLY-ASSISTED-VAGINAL-HYSTERECTOMY-ENLARGED-UTERUS

CPT 58553: Laparoscopically Assisted Vaginal Hysterectomy for Enlarged Uterus

Showing 1–10 of 25

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

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CPT 58558: Hysteroscopic Endometrial Biopsy and Polypectomy

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Billing Code Overview

OpenPayer

CPT 58558: Hysteroscopic Endometrial Biopsy and Polypectomy

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

CPT 58558: Hysteroscopic Endometrial Biopsy and Polypectomy

Sign up for cpt 58558 policy alerts

Billing Code Overview

CPT 58558: Hysteroscopic Endometrial Biopsy and Polypectomy

Sign up for cpt 58558 policy alerts

Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What procedures and services does CPT 58558 cover?

What is the typical clinical workflow for a case billed with CPT 58558?

Which related CPT and pathology codes are relevant when billing 58558?

Which modifiers are commonly applicable to CPT 58558 and when are they used?

Which provider specialties and facility taxonomy codes are associated with performing and billing CPT 58558?

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What procedures and services does CPT 58558 cover?

What is the typical clinical workflow for a case billed with CPT 58558?

Which related CPT and pathology codes are relevant when billing 58558?

Which modifiers are commonly applicable to CPT 58558 and when are they used?

Which provider specialties and facility taxonomy codes are associated with performing and billing CPT 58558?

References