Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Office endometrial biopsy not attempted first - less invasive option available
Very Common58558 (hysteroscopy with biopsy) denials occur when office endometrial biopsy (58100) not attempted first. Insurance expects trial of office-based sampling before approving operative hysteroscopy requiring anesthesia and facility fees.
Common Causes
- • Hysteroscopy requested as first-line sampling method
- • No documentation of attempted office endometrial biopsy
- • Office biopsy not attempted due to patient anxiety - not documented
Resolution Strategy
Appeal with documentation showing: office endometrial biopsy attempted but inadequate tissue obtained (pathology report showing insufficient sample), patient unable to tolerate office biopsy (cervical stenosis preventing instrument passage, severe patient discomfort preventing adequate sampling), or clinical factors making hysteroscopy more appropriate (known endometrial polyp requiring removal, thickened endometrium >20mm suggesting focal lesion better sampled under direct visualization). If office biopsy never attempted, unlikely to approve hysteroscopy without trial. Recommend attempting office biopsy first, documenting result/reason for failure, then hysteroscopy appropriate.
2. Postmenopausal bleeding evaluation - endometrial thickness <5mm on ultrasound
CommonFor postmenopausal bleeding workup, endometrial thickness <4-5mm on transvaginal ultrasound has very low risk of endometrial cancer (negative predictive value >99%). Insurance may deny hysteroscopy when thin endometrial stripe makes cancer unlikely and less invasive evaluation sufficient.
Common Causes
- • Ultrasound shows endometrial thickness 3mm - very low cancer risk
- • Bleeding attributed to atrophic vaginitis, not endometrial source
- • Single episode of minimal bleeding, endometrium thin on imaging
Resolution Strategy
For thin endometrium (<4mm) with postmenopausal bleeding: appeal arguing atypical features warrant direct visualization (recurrent bleeding despite thin stripe, bleeding after endometrial ablation, high-risk factors such as Lynch syndrome, patient on tamoxifen with complex sonographic appearance). If truly thin regular endometrial stripe with single bleeding episode, observation or atrophic vaginitis treatment is appropriate and appeal unlikely successful. For recurrent bleeding even with thin endometrium, appeal stronger. Guideline: endometrial thickness ≥4-5mm warrants sampling, <4mm can often observe.
3. Polypectomy performed - should use different code based on polyp removal method
Occasional58558 includes polypectomy (polyp removal) as part of hysteroscopy with biopsy. However, if fibroid (not polyp) removed, different code required (58561). Denials occur when procedure description doesn't match code used or when more extensive resection performed.
Common Causes
- • Submucosal fibroid removed - should use 58561, not 58558
- • Extensive endometrial ablation performed - should use 58563, not 58558
- • Multiple large polyps requiring morcellation - may require different coding
Resolution Strategy
Review operative report and pathology. Polyp (endometrial polyp) = 58558 appropriate. Submucosal fibroid = recode to 58561. Endometrial ablation = recode to 58563. Simple biopsy sampling without polyp removal = may be diagnostic hysteroscopy 58555. Corrected claim with appropriate code based on procedure actually performed should resolve. Include operative report and pathology report with corrected claim showing polyp vs fibroid vs endometrial tissue sampled.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Hysteroscopic examination of uterine cavity with tissue sampling or polyp removal
Common Scenarios
Documentation Requirements
- Indication for procedure (abnormal bleeding, polyp, etc.)
- Pre-operative ultrasound or imaging findings
- Hysteroscopic findings (endometrial appearance, polyps, fibroids)
- Tissue sampling method (targeted biopsy, polypectomy, D&C)
- Pathology report confirming tissue diagnosis
Coding Guidelines
Common Modifiers
Bundling Rules
- Includes diagnostic hysteroscopy, biopsy, and D&C if performed
- Cannot bill 58100 (endometrial biopsy) separately
- Cannot bill 58120 (D&C only) separately
- Pathology interpretation separately billable
Exclusions
- Do not use for diagnostic hysteroscopy only (use 58555)
- Cannot bill if fibroid resection performed (use 58561)
- Do not use for office endometrial biopsy (use 58100)
- Cannot bill with 58563 (endometrial ablation) for same session
Coding Notes
Related CPT Codes
Clinical scenarios
- Indication for procedure (abnormal bleeding, polyp, etc.)
- Pre-operative ultrasound or imaging findings
- Hysteroscopic findings (endometrial appearance, polyps, fibroids)
- Indication for procedure (abnormal bleeding, polyp, etc.)
- Pre-operative ultrasound or imaging findings
- Hysteroscopic findings (endometrial appearance, polyps, fibroids)
- Indication for procedure (abnormal bleeding, polyp, etc.)
- Pre-operative ultrasound or imaging findings
- Hysteroscopic findings (endometrial appearance, polyps, fibroids)
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PFSRVU Breakdown
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Ask a QuestionFrequently Asked Questions
CPT 58558 is the billing code for "Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C". Hysteroscopic examination of uterine cavity with tissue sampling or polyp removal
Medicare pays approximately $1207.17 for CPT 58558 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 58558 has a total RVU of 21.20, broken down as: Work RVU 4.20, Practice Expense RVU 15.60, and Malpractice RVU 1.40. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 58558 is "Office endometrial biopsy not attempted first - less invasive option available". 58558 (hysteroscopy with biopsy) denials occur when office endometrial biopsy (58100) not attempted first. Insurance expects trial of office-based sampling before approving operative hysteroscopy requiring anesthesia and facility fees. Common causes include: Hysteroscopy requested as first-line sampling method; No documentation of attempted office endometrial biopsy. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 58558 include: Indication for procedure (abnormal bleeding, polyp, etc.); Pre-operative ultrasound or imaging findings; Hysteroscopic findings (endometrial appearance, polyps, fibroids); Tissue sampling method (targeted biopsy, polypectomy, D&C). Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 58558: Includes diagnostic hysteroscopy, biopsy, and D&C if performed. Cannot bill 58100 (endometrial biopsy) separately Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 58558 include: 50 (Not applicable (single uterus)), 22 (Increased complexity (severe adhesions, difficult access)), 52 (Reduced services (if procedure incomplete)). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 58558 is 30-60 minutes including cervical dilation and closure. Time-based codes require documentation of the actual time spent providing the service.