Summary & Overview
CPT 58561: Hysteroscopic Myomectomy, Intracavitary Fibroid Removal
CPT code 58561 denotes hysteroscopic myomectomy: removal of intracavitary uterine leiomyomata (fibroids) under direct hysteroscopic visualization. This procedure is a commonly utilized minimally invasive option for symptomatic intracavitary fibroids and is clinically significant for preserving uterine anatomy while addressing bleeding, infertility, or bulk symptoms. Nationally, coding accuracy for hysteroscopic myomectomy affects surgical quality metrics, facility utilization, and payer coverage determinations.
Key payers covered in the analysis include Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context and sites of service, common billing modifiers flagged for review, and what to expect in payer coverage considerations. The publication summarizes typical billing practices, related procedural coding considerations, and where stakeholders often focus audits and medical necessity reviews.
This summary equips clinicians, coding professionals, and policy analysts with the essential framing of CPT code 58561, clarifying why correct CPT coding matters for procedural reporting, reimbursement pathways, and alignment with quality measurement in gynecologic surgery. Data not available in the input for some specific benchmarks and payer policy details.
Billing Code Overview
CPT code 58561 describes a surgical procedure in which the provider removes uterine leiomyomata (fibroids) using a hysteroscope. The procedure involves transcervical access with direct visualization of the uterine cavity to excise or morcellate intracavitary fibroids.
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Service type: Hysteroscopic myomectomy (operative hysteroscopy)
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Typical site of service: Ambulatory surgery center or hospital outpatient department; may also be performed in inpatient settings depending on clinical complexity and patient factors.
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Clinical & Coding Specifications
Clinical Context
A 38-year-old woman presents with heavy menstrual bleeding, pelvic pressure, and confirmed submucosal uterine fibroids on transvaginal ultrasound and diagnostic hysteroscopy. Conservative medical therapy failed to control symptoms. The gynecologist schedules an operative hysteroscopic myomectomy to remove intracavitary leiomyomata. On the day of service, the patient undergoes preoperative evaluation, informed consent, and general anesthesia in an ambulatory surgery center. The provider uses a hysteroscope with operative instruments to visualize the uterine cavity and resect or morcellate fibroid tissue. Intraoperative findings, estimated blood loss, number and size of fibroids removed, and any complications are documented. The workflow includes same-day recovery, discharge instructions addressing bleeding and infection signs, and a postoperative follow-up visit to assess symptom improvement and healing.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
51 | Multiple procedures | Use when additional distinct procedures are billed with 58561 during the same operative session and payer permits multiple procedure billing. |
52 |