CPT® Code 58558

A surgical hysteroscopy with sampling (biopsy) of the endometrium and/or polypectomy is a minimally invasive procedure that allows for direct visualization and intervention within the uterine cavity. This procedure is performed to diagnose and treat various uterine conditions, including abnormal bleeding, polyps, and fibroids. Prior to the insertion of the hysteroscope, a bimanual pelvic examination is conducted to assess the uterus and surrounding structures. A single-tooth tenaculum is then applied to the anterior cervical lip to stabilize the cervix, and a sound is utilized to measure the depth and angle of the uterus, ensuring proper placement of the hysteroscope. The cervix is anesthetized and dilated using metal dilators, facilitating the insertion of the hysteroscope into the endocervical canal. The hysteroscope is advanced into the uterine cavity under direct visualization, while the uterus is expanded using saline or carbon dioxide to provide a clear view of the internal structures. During the procedure, the physician examines the uterine lining for any abnormalities such as polyps or fibroids. If necessary, an endometrial curette or thin-wire biopsy forceps are introduced through the cervix to obtain tissue samples from multiple sites within the uterus for histological analysis. Any identified polyps are excised during this process. Should a dilation and curettage (D&C) be indicated, a curette is inserted to scrape or suction the uterine wall, allowing for thorough removal of tissue. The collected specimens are then sent for pathology examination to aid in diagnosis. Finally, all instruments are carefully removed, and any bleeding from the cervix is managed through the application of pressure to ensure patient safety and comfort.