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Basics about Polypectomy & Myomectomy CPT code

Endometrial polyps are one of the most common causes of abnormal vaginal bleeding in both premenopausal and postmenopausal women. Endometrial polyps can also be an overgrowth (tumor) of cells. Hence, polypectomy is done to get rid of such harmful diseases. Polypectomy is a minimally invasive procedure in which doctors remove abnormal growths of tissue, called polyps, from inside your colon. The exam is done through hysteroscopy. In surgery, we have separate CPT code 58558, used for reporting polypectomy through hysteroscopy.

There are complex procedure in surgery like LEEP procedure, gastrostomy, bunionectomy, closed fracture treatment etc. which are coded very frequently by coders.

Also, their are uterine fibroids, which are also called as leiomyomas, an abnormal growth that develops in women’s uterus. Myomas are benign tumors composed partly of muscle tissue. Hence, myomectomy is performed to get remove myomas. Myomectomy is a surgical procedure to remove uterine fibroids also called leiomyomas. CPT code 58561, is used to report hysteroscopy surgical removal of myomas.

Code description of CPT code for Polypectomy & Myomectomy

Both polypectomy & myomectomy are performed using hysteroscopy, a procedure that allows your doctor to look inside your uterus in order to diagnose and treat causes of abnormal bleeding. Surgical hysteroscopy is performed to remove polyps and myomas.

For CPT code 58558, the physician performs a diagnostic inspection of the uterus using a hysteroscope and removes a uterine polyp, removes uterine tissue for biopsy, and may perform cervical dilation and uterine curettage (D&C). The physician advances the hysteroscope through the vagina and into the cervical os to gain entry into the uterine cavity. The physician inspects the uterine cavity with the fiberoptic scope and removes a sample of the uterine lining and/or removes a growth (polypectomy) within the uterus and may perform a cervical dilation and uterine curettage, scraping (D&C) to take a complete sampling of the uterine lining.

58555 – Hysteroscopy, diagnostic (separate procedure)

Surgical Hysteroscopy will always include diagnostic hysteroscopy, hence a diagnostic hysteroscopy should not be reported with a surgical hysteroscopy.

58558– Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C

Surgical hysteroscopy for polypectomy can be performed with or without dilation and curettage. (D&C). The exam is performed using a hysteroscope, which is placed into the endocervical canal and advanced into the uterine cavity. The uterus is examined for polyps, fibroids, or other abnormalities using hysteroscopy. An endometrial curette or thin wire biopsy forceps are passed through the cervix and biopsies are taken from multiple sites in the uterus. If any polyps are found, they are removed. If a D&C is needed, a curette is inserted through the cervix and the uterine wall is scraped or suctioned.

58561 – Hysteroscopy, surgical; with removal of leiomyomata

Similar procedure is performed for removal of myomas using hysteroscope. Myomas or fibroid tumors may be submucous, intramural, subserous, or pedunculated. Submucous fibroids grow within the endometrial lining of the uterus and protrude into the uterine cavity. The uterus is examined and the size, number, and location of leiomyomata are noted and all are removed using a resectoscope, scissors, or laser.

Intraservice performed for CPT code 58558

A bimanual pelvic examination is performed to assess uterine size, position, and mobility. The adnexa and posterior cul de sac are palpated for the presence of masses or nodularity. The bladder is drained with a catheter. The cervix is exposed, grasped, and dilated to accommodate the diagnostic hysteroscope. The uterine sound is passed. The hysteroscope is inserted, and the proper pressure setting of the pump or gravity flow is confirmed to adequately distend the endometrial cavity. The entire endometrial cavity, including the anterior, posterior, fundal, and lateral walls and both tubal ostia, is examined. The endocervical canal is examined.

An irregular polypoid mass is identified. The cervix is further dilated to admit the operative hysteroscope and excise the entire lesion(s). Fluid volumes are continuously monitored. Bleeding points are coagulated, and the hysteroscope is removed from the uterus. Curettage of the endometrial cavity is performed. The hysteroscope is replaced for visual reinspection of the entire cavity. The cervix is checked for bleeding from a puncture site or laceration. All instruments are removed from the vagina and cervix.