© Copyright 2025 American Medical Association. All rights reserved.
A surgical hysteroscopy with endometrial ablation is a minimally invasive procedure that involves the use of a hysteroscope, a thin, lighted tube, to visualize the inside of the uterus. This procedure is specifically designed to treat conditions associated with excessive or abnormal uterine bleeding, known as menorrhagia. During the procedure, various techniques may be employed for the ablation of the endometrium, which is the inner lining of the uterus. These techniques include endometrial resection, electrosurgical ablation, and thermoablation, each of which effectively removes or destroys the endometrial tissue to alleviate bleeding. Prior to the insertion of the hysteroscope, a bimanual pelvic examination is conducted to assess the uterus and surrounding structures. The cervix is then prepared for the procedure by applying a single-tooth tenaculum to the anterior cervical lip, which helps stabilize the cervix. A sound is passed through the cervix to measure the depth and angle of the uterus, ensuring proper placement of the hysteroscope. The cervix is numbed and dilated using metal dilators, allowing for the safe insertion of the hysteroscope into the endocervical canal and advancement into the uterine cavity. To facilitate visualization and access, the uterine cavity is expanded using either saline or carbon dioxide. Once the hysteroscope is in place, the uterine cavity is thoroughly examined. The ablation process begins with the application of an electrosurgical roller-ball, which delivers electric current to the endometrial tissue, starting at the uterine horns and progressing through the cornua, tubal angles, and the walls of the uterus. Alternatively, thermoablation may be performed using a balloon catheter filled with heated fluid, which is applied against the endometrial lining to achieve the desired effect. In some cases, a resectoscope may be utilized, which features a built-in wire that conducts electrical current to resect the endometrial tissue in strips, which are then removed using polyp forceps. After the procedure, all instruments are carefully removed, and any bleeding from the cervical lip is managed through the application of pressure.
© Copyright 2025 Coding Ahead. All rights reserved.
The surgical hysteroscopy with endometrial ablation is indicated for the treatment of conditions associated with excessive or abnormal uterine bleeding, particularly in cases where conservative management has failed or is not appropriate. The following conditions may warrant this procedure:
The procedure of surgical hysteroscopy with endometrial ablation involves several key steps that ensure effective treatment while minimizing risks. The following outlines the procedural steps:
Following the surgical hysteroscopy with endometrial ablation, patients are typically monitored for any immediate complications. Post-procedure care may include instructions for managing discomfort, such as the use of over-the-counter pain relievers. Patients may experience some cramping and light bleeding, which is expected as the uterus heals. It is important for patients to follow up with their healthcare provider to assess the effectiveness of the procedure and to monitor for any potential complications. Additionally, patients should be advised to report any signs of excessive bleeding, fever, or unusual pain, as these may indicate complications that require further evaluation.
| Short Descr | HYSTEROSCOPY ABLATION | Medium Descr | HYSTEROSCOPY ENDOMETRIAL ABLATION | Long Descr | Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) | 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 |
| 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). | 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. | 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.) | 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 | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GC | This service has been performed in part by a resident under the direction of a teaching physician | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SG | Ambulatory surgical center (asc) facility service | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2011-01-01 | Changed | Short description changed. |
| 2002-01-01 | Changed | Code description changed. |
| 2000-01-01 | Added | First appearance in code book in 2000. |
Get instant expert-level medical coding assistance.