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Official Description

Hysteroscopy, surgical; with removal of impacted foreign body

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

A surgical hysteroscopy is a minimally invasive procedure that involves the use of a hysteroscope, a thin, lighted tube, to visualize and access the interior of the uterus. This specific procedure, identified by CPT® Code 58562, is performed to remove an impacted foreign body, which may include items such as an intrauterine device (IUD) that has become lodged or displaced within the uterine cavity. Prior to the insertion of the hysteroscope, a bimanual pelvic examination is conducted to assess the uterus and surrounding structures. This examination helps in determining the appropriate approach for the procedure. To facilitate the hysteroscopy, a single-tooth tenaculum is applied to the anterior lip of the cervix, providing stability during the procedure. A sound, which is a slender instrument, is then passed through the cervix 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, which allows for the safe insertion of the hysteroscope into the endocervical canal. Once the hysteroscope is in place, it is advanced into the uterine cavity under direct visualization, while the cavity is simultaneously expanded using saline or carbon dioxide to improve visibility and access. The surgeon carefully examines the uterine cavity to locate the foreign body. Upon identification, the foreign body is grasped with a toothed grasper and gently pulled toward the hysteroscope sheath for removal. After the successful extraction of the foreign body, both the hysteroscope and the grasper are withdrawn from the uterus. Finally, the tenaculum is removed from the cervical lip, and any bleeding that may occur is managed through the application of pressure. This procedure is essential for addressing complications associated with retained foreign bodies in the uterus, ensuring patient safety and comfort.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The surgical hysteroscopy with removal of an impacted foreign body, as described by CPT® Code 58562, is indicated for specific clinical scenarios where a foreign object is present within the uterine cavity. The following conditions may warrant this procedure:

  • Impacted Intrauterine Device (IUD) - The procedure is commonly performed when an IUD has become dislodged or embedded within the uterine wall, causing discomfort or complications.
  • Retained Foreign Body - This includes any other foreign objects that may have been inadvertently left in the uterus, which can lead to pain, infection, or abnormal bleeding.
  • Uterine Abnormalities - The presence of foreign bodies may be associated with other uterine abnormalities that require evaluation and intervention.

2. Procedure

The procedure for surgical hysteroscopy with removal of an impacted foreign body involves several critical steps to ensure safety and effectiveness. Each step is outlined as follows:

  • Step 1: Bimanual Pelvic Examination - Before the hysteroscope is inserted, a bimanual pelvic examination is performed. This examination allows the physician to assess the size, shape, and position of the uterus and any associated structures, providing essential information for the procedure.
  • Step 2: Cervical Stabilization - A single-tooth tenaculum is placed on the anterior lip of the cervix. This instrument helps stabilize the cervix during the procedure, ensuring that the hysteroscope can be inserted accurately and safely.
  • Step 3: Uterine Measurement - A sound is passed through the cervix to measure the depth and angle of the uterine cavity. This step is crucial for determining the appropriate insertion technique for the hysteroscope.
  • Step 4: Cervical Anesthesia and Dilation - The cervix is numbed using a local anesthetic, and metal dilators are used to dilate the cervix. This dilation is necessary to allow for the smooth passage of the hysteroscope into the uterine cavity.
  • Step 5: Hysteroscope Insertion - The hysteroscope is carefully inserted into the endocervical canal and advanced into the uterine cavity under direct visualization. During this process, the uterine cavity is expanded using saline or carbon dioxide, which enhances visibility and access.
  • Step 6: Examination and Foreign Body Removal - Once the hysteroscope is in place, the physician examines the uterine cavity to locate the impacted foreign body. Upon identification, the foreign body is grasped with a toothed grasper and pulled toward the hysteroscope sheath for removal.
  • Step 7: Withdrawal of Instruments - After the foreign body has been successfully removed, both the hysteroscope and the grasper are withdrawn from the uterus simultaneously, ensuring that no additional trauma occurs to the uterine lining.
  • Step 8: Cervical Tenaculum Removal and Hemostasis - The tenaculum is removed from the cervical lip, and any bleeding that may occur is controlled through the application of pressure, ensuring patient safety and comfort post-procedure.

3. Post-Procedure

After the completion of the surgical hysteroscopy, patients may experience some cramping or spotting, which is typically mild and resolves quickly. It is important for patients to be monitored for any signs of complications, such as excessive bleeding or infection. Follow-up care may include instructions on activity restrictions, signs of complications to watch for, and scheduling a follow-up appointment to assess recovery. Patients are advised to avoid sexual intercourse, tampons, and douching for a specified period as directed by their healthcare provider to promote healing and prevent infection.

Short Descr HYSTEROSCOPY REMOVE FB
Medium Descr HYSTEROSCOPY REMOVAL IMPACTED FOREIGN BODY
Long Descr Hysteroscopy, surgical; with removal of impacted foreign body
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) 1 - Statutory 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 229 - Nonoperative removal of foreign body
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.
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.
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure 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
GC This service has been performed in part by a resident under the direction of a teaching physician
SG Ambulatory surgical center (asc) facility service
Date
Action
Notes
2011-01-01 Changed Short description changed.
2000-01-01 Added First appearance in code book in 2000.
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