CPT Code 58558: Hysteroscopy Biopsy and Polypectomy Billing Guide (2026)

What Is CPT Code 58558?

CPT code 58558 is a surgical hysteroscopy code that reports sampling (biopsy) of the endometrium and/or polypectomy, with or without a dilation and curettage. As of 2026, it carries a 0-day global period, already includes the diagnostic hysteroscopy (58555) and any same-session D&C, and is reported once per operative session no matter how many polyps or biopsies are taken.

What is bundled into it: 58558 already includes diagnostic hysteroscopy (58555) and a same-session D&C, so billing those on their own is an unbundling denial.

When it is the wrong code: A hysteroscopic myomectomy is 58561 and an ablation is 58563, and each absorbs a same-session 58558; removing an impacted IUD or foreign body is 58562.

Whether it needs a modifier: Usually no. 58558 stands alone, though its 0-day global period allows a separately identifiable same-day office visit with modifier 25.

What 58558 Includes, Not Billed Separately

This is where the revenue actually leaks. CPT 58558 is the base operative code in the hysteroscopy family, and several common services are already inside it. Diagnostic hysteroscopy (58555) is the foundation of the family and is included in every higher code, so 58555 and 58558 cannot be reported together for the same session. When a dilation and curettage is done through or alongside the scope in the same session, it is part of 58558; reporting the D&C on its own is a classic unbundling error. A standalone endometrial biopsy code such as 58100 is likewise mutually exclusive with 58558 for the same session.

The procedure also bundles upward. When a more extensive procedure in the same family is performed in the same session, 58558 is included in it and is not separately billable. The two most common are 58561 (hysteroscopic removal of fibroids) and 58563 (endometrial ablation). These are hard NCCI bundles, and a modifier 59 will not break them, so bill only the more extensive code. For Medicare, a paracervical block placed by the operating surgeon (64435) is considered part of the procedure and is not separately payable.

Across the OB-GYN billing companies we vet, hysteroscopy is one of the most common places we see unbundling denials, usually because the diagnostic look or the D&C gets keyed as its own line out of habit. The polyp that leads to a 58558 is often first identified on a transvaginal ultrasound (CPT 76830) or a sonohysterogram, and that imaging is separately reportable at the earlier encounter, but it does not change how the operative session itself is coded.

The Hysteroscopy Code Family

Two questions sort most of this family: was the hysteroscopy purely diagnostic, or was something done, and if something was done, what was it? CPT 58558 is the biopsy-or-polypectomy code, the first operative step up from a diagnostic look. Within one session you report the single most extensive code that captures the work, not a stack of family members. The table below maps the range, per the AMA CPT code set.

CPT	What it reports
58555	Diagnostic hysteroscopy only (the base code, included in all of the below)
58558	Surgical hysteroscopy with endometrial biopsy and/or polypectomy, with or without D&C
58559	With lysis of intrauterine adhesions
58560	With division or resection of an intrauterine septum
58561	With removal of fibroids (leiomyomata)
58562	With removal of an impacted foreign body
58563	With endometrial ablation
58565	With tubal cannulation and placement of permanent occlusion implants

It also helps to know what is not 58558. A purely diagnostic hysteroscopy is 58555. Removing an impacted IUD or other foreign body through the scope is 58562. A hysteroscopic myomectomy is 58561, and it includes any biopsy or polypectomy done in the same session. An endometrial ablation is 58563, which likewise absorbs a same-session 58558. When definitive surgery is chosen instead of a scope-based procedure, the claim moves to a different family entirely, such as a laparoscopic hysterectomy under CPT 58571.

What Is the Difference Between 58555 and 58558?

58555 is a diagnostic hysteroscopy only, a look inside the uterine cavity with no tissue removed. 58558 is the surgical version that adds an endometrial biopsy and/or a polypectomy, with or without a D&C. Because 58555 is the base code, it is always included in 58558 and is never reported separately for the same session.

The practical test is whether tissue was sampled or removed. If the operative note documents only visualization, the correct code is 58555. The moment the surgeon takes an endometrial biopsy or removes a polyp through the same scope, the encounter becomes 58558, and the diagnostic component folds into it. Coding both is the single most common error in this family, and it draws an immediate mutually-exclusive edit.

Payment follows the same logic. 58558 pays more than 58555 because it captures the added operative work of the biopsy or polypectomy, so upcoding a purely diagnostic look to 58558 is an overpayment risk, while downcoding an operative session to 58555 leaves earned revenue on the table. The deciding document is the operative note: it has to state that the scope was introduced and that tissue was sampled or a polyp removed. When the note is vague about whether anything was taken, the claim is exposed either to a denial or to a downcode on review, so the language in the report is what protects the code.

Does CPT 58558 Need a Modifier?

In the routine case, no. CPT 58558 is a complete operative code that already includes the diagnostic look and any D&C, so it usually stands on its own. Modifiers come into play only when the clinical scenario calls for them, and appending one without support is its own denial risk.

• Modifier 22 (Increased Procedural Services): when the work is substantially greater than typical, for example dense adhesions or unusually difficult access. It needs an operative note that quantifies the extra effort, and usually a cover letter.
• Modifier 52 (Reduced Services): when the planned procedure is partially reduced or less extensive than the code describes.
• Modifier 53 (Discontinued Procedure): when the procedure is started but stopped, typically for the patient’s wellbeing.
• Modifier 51 (Multiple Procedures): when a separate, unrelated procedure is performed in the same session. Many payers apply this automatically, so confirm whether yours wants it appended.
• Modifier 59 or the XE, XS, XU subset: to identify a genuinely distinct procedural service when an NCCI edit would otherwise bundle it. Note the limit: 59 will not unbundle 58558 from 58561 or 58563.
• Modifier 25 on a same-day E/M: because 58558 carries a 0-day global period, a significant, separately identifiable office visit on the same day can be reported with modifier 25. This differs from major surgery, where routine same-day E/M is bundled.

In our experience matching OB-GYN practices with billing partners, the modifier that causes the most trouble here is 25, because a same-day visit that is really just the pre-operative assessment is not separately identifiable and will not survive a records request. The visit has to stand on its own in the note.

CPT 58558 Reimbursement in 2026

CPT 58558 carries a 0-day global period, a meaningful difference from major procedures like a hysterectomy. A 0-day global covers only the care on the day of the procedure, so a later, medically necessary follow-up visit can be separately billable when the diagnosis supports it. Two factors move the payment more than anything else.

Setting is the biggest swing. When the procedure is done in the office (non-facility), the practice absorbs the cost of the scope, the fluid management system, and the disposables, so the non-facility payment is higher to account for that practice expense. When it is done in a hospital outpatient department or an ASC, the facility is paid separately and the physician allowable is lower, so the place of service has to be coded accurately. The second factor is same-day E/M discounting: when an office visit is billed on the same day as an office hysteroscopy, the visit’s practice-expense RVUs are reduced, since the patient is already in the chair.

Medicare payment otherwise follows the standard formula: total RVUs (work plus practice expense plus malpractice) multiplied by the annual conversion factor, then adjusted for locality. Two 2026 specifics matter. Under the CY 2026 Medicare Physician Fee Schedule, CMS finalized an efficiency adjustment of roughly 2.5 percent that lowered work RVUs for most non-time-based codes, and surgical codes like 58558 fall into that group while time-based E/M codes are excluded. There are also two 2026 conversion factors, a qualifying-APM factor and a non-qualifying factor, so the exact allowable depends on which applies. Because the dollar amount shifts every January, varies by setting, and varies by payer, verify the current allowable in the Medicare Physician Fee Schedule for the relevant year, locality, and setting, and against each contract.

Common 58558 Denials and Fixes

Providers often come to us after a run of hysteroscopy denials that trace back to the same handful of causes. Each one is a process fix, not a one-off correction.

• Diagnostic hysteroscopy billed separately. 58555 is reported alongside 58558. Fix: 58555 is included, so report 58558 alone.
• D&C billed separately. A curettage code is added to the claim. Fix: when a hysteroscope is used, the curettage is part of 58558, so do not unbundle it.
• Billed with a more extensive family code. 58558 is reported with 58561 or 58563. Fix: these are bundled and modifier 59 will not break them, so bill only the more extensive code.
• Reported more than once per session. A unit is billed for each polyp or biopsy. Fix: 58558 is one unit per operative session regardless of how many specimens are taken.
• Missing medical necessity. The diagnosis does not support surgery. Fix: link a supported ICD-10 code, such as an endometrial polyp (N84.0), abnormal uterine bleeding (N93 or N92 family), postmenopausal bleeding (N95.0), or endometrial hyperplasia (N85.0 family).
• Wrong code for the actual work. 58558 is used for an impacted IUD removal. Fix: that is 58562, not 58558.
• Documentation gaps. The note does not confirm a hysteroscope was used, or the pathology requisition is not tied to the operative note. Fix: state that the scope was introduced and used, describe the biopsy or polypectomy, note whether a D&C was performed, and attach the pathology requisition.

For a wider look at why OB-GYN claims bounce and how to work them, see our guide to handling claim denials for your OB-GYN practice.

In-House vs Outsourced OB-GYN Billing

Whether to keep hysteroscopy billing in house or outsource it comes down to surgical volume, payer mix, and how much revenue is currently leaking at this code. A single-provider practice with clean payer relationships and low operative volume may code 58558 well in house. A busy gynecology group performing regular hysteroscopies, myomectomies, and ablations, each with its own bundling rules, often finds that a specialized partner recovers more than the service costs simply by catching the unbundling and the mis-selected family codes that an overstretched in-house biller misses.

The honest test is whether your practice can say how many 58558 claims were denied or downcoded last quarter, and why. If you cannot, that blind spot is where the money leaks. OB-GYN Bill Co connects practices with vetted billing companies across all 50 states, backed by more than 2,000 providers matched, over 15 years in medical billing, and rates starting as low as 2.95 percent, with a matched partner typically in touch within about 30 minutes of a verified request.

You do not have to hand off the entire revenue cycle to benefit. Even a practice that keeps billing in house can bring in a vetted partner to audit its hysteroscopy coding pattern, confirm the operative template captures what the code requires, and build a payer-by-payer bundling grid so the same edits stop repeating. As a matching platform rather than a biller, OB-GYN Bill Co reviews each practice’s specialty focus, volume, and EHR before making an introduction, so the partner already understands hysteroscopy bundling rather than learning them on your claims.

Frequently Asked Questions

Next Steps

• Confirm your operative template captures the scope, the biopsy or polypectomy, and whether a D&C was performed, so 58558 is documented cleanly.
• See how the imaging that precedes a hysteroscopy is coded in our guide to transvaginal ultrasound, CPT 76830.
• If hysteroscopy or hysterectomy denials are piling up, review our guide to handling claim denials for your OB-GYN practice.