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The CPT® Code 58559 refers to a surgical procedure known as hysteroscopy with lysis of intrauterine adhesions. This procedure is performed to address intrauterine adhesions, which are also known as synechiae or scar tissue. These adhesions can form within the uterine cavity and may lead to complications such as infertility, abnormal menstrual bleeding, or other reproductive issues. The procedure begins with a thorough bimanual pelvic examination to assess the condition of the uterus and surrounding structures. Following this, a single-tooth tenaculum is applied to the anterior cervical lip to stabilize the cervix during the procedure. A sound is then introduced to measure the depth and angle of the uterus, ensuring proper placement of the hysteroscope. To facilitate the insertion of the hysteroscope, the cervix is numbed and dilated using metal dilators. The hysteroscope is then carefully inserted into the endocervical canal and advanced into the uterine cavity under direct visualization, while the uterus is simultaneously expanded using saline or carbon dioxide. This expansion allows for a clear view of the uterine lining and any existing adhesions or intrauterine septum. The primary goal of the procedure is to identify and lyse the intrauterine adhesions, which can be accomplished through various methods such as blunt dissection, scissors, or laser techniques. Once the adhesions are successfully removed, the tubal openings, or ostia, are visualized to ensure they are clear. Finally, all surgical instruments, including the hysteroscope, are withdrawn, and the tenaculum is removed from the cervical lip. Any bleeding from the cervix is managed through the application of pressure, concluding the procedure.
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The procedure described by CPT® Code 58559 is indicated for the treatment of intrauterine adhesions, which can lead to various reproductive health issues. The following conditions may warrant the performance of this procedure:
The surgical procedure for CPT® Code 58559 involves several critical steps to ensure effective treatment of intrauterine adhesions. The process begins with a bimanual pelvic examination, which allows the physician to assess the uterus and surrounding structures for any abnormalities. Following this examination, a single-tooth tenaculum is applied to the anterior cervical lip to stabilize the cervix during the procedure. This is essential for maintaining control and access to the uterine cavity. Next, a sound is passed through the cervix to determine the depth and angle of the uterus, which is crucial for the accurate placement of the hysteroscope. To facilitate this insertion, the cervix is numbed and dilated using metal dilators, allowing for easier access to the uterine cavity. Once the cervix is adequately prepared, the hysteroscope is inserted into the endocervical canal and advanced into the uterine cavity under direct visualization. During this step, the uterus is expanded using either saline or carbon dioxide, which provides a clear view of the uterine lining and any adhesions present. Upon entering the uterine cavity, the physician examines the uterus for the presence of adhesions or an intrauterine septum. The primary focus of the procedure is to lyse the intrauterine adhesions, which may be accomplished through various methods such as blunt dissection, scissors, or laser techniques. All identified adhesions are carefully removed, and the tubal openings (ostia) are visualized to ensure they are unobstructed. After the completion of the lysis, all surgical instruments, including the hysteroscope, are removed from the uterine cavity. Finally, the tenaculum is taken off the cervical lip, and any bleeding from the cervix is controlled through the application of pressure.
After the completion of the hysteroscopy with lysis of intrauterine adhesions, patients may experience some post-procedure care considerations. It is common for patients to have mild cramping or spotting following the procedure, which typically resolves within a few days. Patients are advised to monitor for any signs of excessive bleeding or infection, such as fever or unusual discharge, and to contact their healthcare provider if these symptoms occur. Follow-up appointments may be scheduled to assess recovery and evaluate the success of the procedure in alleviating symptoms related to intrauterine adhesions. Additionally, patients may receive specific instructions regarding activity restrictions and any necessary medications to manage discomfort during the recovery period.
| Short Descr | HYSTEROSCOPY LYSIS | Medium Descr | HYSTEROSCOPY LYSIS INTRAUTERINE ADHESIONS | Long Descr | Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Endoscopic Base Code | 58555 Hysteroscopy, diagnostic (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 125 - Other excision of cervix and uterus |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service |
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| 2011-01-01 | Changed | Short description changed. |
| 2000-01-01 | Added | First appearance in code book in 2000. |
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