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A surgical hysteroscopy is a minimally invasive procedure that involves the use of a hysteroscope, a thin, lighted tube, to visualize and treat conditions within the uterine cavity. This specific procedure, identified by CPT® Code 58561, is performed to remove leiomyomata, commonly known as uterine fibroids. Leiomyomata are benign tumors that develop from the smooth muscle tissue of the uterus, known as the myometrium. These fibroids can vary in location and type, including submucous, intramural, subserous, and pedunculated fibroids. Submucous fibroids are located within the endometrial lining and extend into the uterine cavity, making them particularly amenable to removal via hysteroscopy. Intramural fibroids are embedded within the uterine wall, while subserous fibroids are found on the outer surface of the uterus and may develop a stalk, becoming pedunculated as they grow. Before the procedure begins, a bimanual pelvic examination is conducted to assess the uterus's size and position. Following this, a single-tooth tenaculum is applied to the anterior cervical lip to stabilize the cervix. A uterine sound is then introduced to measure the depth and angle of the uterine cavity, ensuring accurate placement of the hysteroscope. The cervix is anesthetized and dilated using metal dilators to facilitate the insertion of the hysteroscope into the endocervical canal. The hysteroscope is advanced into the uterine cavity under direct visualization, while the cavity is expanded using saline or carbon dioxide to provide a clear view of the internal structures. During the procedure, the surgeon examines the uterus, noting the size, number, and location of the leiomyomata. The fibroids are then excised using specialized instruments such as a resectoscope, scissors, or laser. After the removal of the fibroids, surgical instruments are withdrawn, and any bleeding from the cervix is addressed to ensure patient safety and comfort.
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The surgical hysteroscopy with removal of leiomyomata is indicated for patients presenting with specific symptoms or conditions related to uterine fibroids. These indications may include:
The procedure for surgical hysteroscopy with removal of leiomyomata involves several critical steps to ensure effective treatment. The process begins with a thorough bimanual pelvic examination to assess the uterus's condition. Following this, a single-tooth tenaculum is applied to the anterior cervical lip to stabilize the cervix during the procedure. A uterine sound is then introduced to measure the depth and angle of the uterine cavity, which is essential for accurate hysteroscope placement. Next, the cervix is anesthetized to minimize discomfort, and metal dilators are used to dilate the cervix, allowing for the safe insertion of the hysteroscope. The hysteroscope, equipped with a camera and light source, is carefully placed into the endocervical canal and advanced into the uterine cavity under direct visualization. During this step, the uterine cavity is expanded using saline or carbon dioxide, providing a clear view of the internal structures. Once the hysteroscope is in place, the surgeon conducts a thorough examination of the uterine cavity, noting the size, number, and location of the leiomyomata. The fibroids are then excised using specialized instruments such as a resectoscope, scissors, or laser, depending on the fibroid's characteristics and location. After the successful removal of the fibroids, all surgical instruments are carefully withdrawn from the uterine cavity. Finally, any bleeding from the cervix is controlled to ensure patient safety and comfort before concluding the procedure.
After the surgical hysteroscopy, patients are typically monitored for a short period to ensure there are no immediate complications. Post-procedure care may include instructions for managing any discomfort, such as the use of over-the-counter pain relievers. Patients may experience some cramping or light bleeding following the procedure, which is generally expected. It is important for patients to follow any specific post-operative instructions provided by their healthcare provider, including recommendations for activity levels and follow-up appointments to monitor recovery and assess the success of the procedure. Additionally, patients should be advised to report any unusual symptoms, such as heavy bleeding or signs of infection, to their healthcare provider promptly.
| Short Descr | HYSTEROSCOPY REMOVE MYOMA | Medium Descr | HYSTEROSCOPY REMOVAL LEIOMYOMATA | Long Descr | Hysteroscopy, surgical; with removal of leiomyomata | 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) | 0 - 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 |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient 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). | 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GW | Service not related to the hospice patient's terminal condition | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main 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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