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The procedure described by CPT® Code 58560 refers to a surgical hysteroscopy that involves the division or resection of an intrauterine septum using any method. An intrauterine septum is a congenital anomaly where a fibrous or muscular band divides the uterine cavity, which can lead to complications such as recurrent pregnancy loss or infertility. The surgical approach begins with a thorough bimanual pelvic examination to assess the uterus and surrounding structures. Following this, a single-tooth tenaculum is applied to the anterior lip of the cervix to stabilize it during the procedure. A sound is then introduced into the uterus to measure its depth and angle, ensuring proper placement of the hysteroscope. To facilitate the insertion of the hysteroscope, the cervix is anesthetized and dilated using metal dilators. The hysteroscope is then carefully inserted into the endocervical canal and advanced into the uterine cavity while simultaneously distending the uterus with saline or carbon dioxide. This distension allows for clear visualization of the uterine cavity, where the surgeon can identify any adhesions or the presence of an intrauterine septum. If intrauterine adhesions are present, they may be addressed in a separate procedure coded as CPT® 58559, which involves lysing the adhesions using various techniques. In the case of CPT® 58560, the focus is on the intrauterine septum, which is divided or resected using specialized instruments such as a resectoscope, scissors, or a vaporizing electrode. After the procedure, all instruments, including the hysteroscope, are removed, and the tenaculum is taken off the cervical lip. Any bleeding from the cervix is managed through the application of pressure, ensuring patient safety and comfort post-procedure.
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The procedure coded as CPT® 58560 is indicated for patients presenting with specific conditions related to the intrauterine septum. These indications include:
The surgical procedure for CPT® 58560 involves several critical steps to ensure effective division or resection of the intrauterine septum. The steps are as follows:
Post-procedure care following CPT® 58560 involves monitoring the patient for any immediate complications, such as excessive bleeding or infection. Patients are typically advised to rest and may be given specific instructions regarding activity levels and follow-up appointments. It is essential to monitor for any signs of complications, and patients should be informed about potential symptoms that warrant immediate medical attention. Recovery time may vary, but many patients can resume normal activities within a few days, depending on their individual circumstances and the extent of the procedure performed.
| Short Descr | HYSTEROSCOPY RESECT SEPTUM | Medium Descr | HYSTEROSCOPY DIV/RESCJ INTRAUTERINE SEPTUM | Long Descr | Hysteroscopy, surgical; with division or resection of intrauterine septum (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) | 2 - Payment restriction for assistants at surgery does not apply 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). | 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. | AG | Primary physician | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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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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