Summary & Overview
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.
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.
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Service type: Diagnostic and operative hysteroscopy with endometrial biopsy and/or polypectomy
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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 |