CPT code 58562 – Hysteroscopic removal of impacted foreign body

Key takeaways

CPT Code 58562 covers hysteroscopic surgical removal of a physically impacted or embedded foreign body from the uterine cavity, not a routine IUD retrieval.

The operative report must describe the impacted nature of the object, the hysteroscopic approach, and the instruments used for extraction.

Diagnostic hysteroscopy (CPT 58555) is bundled into 58562 per NCCI edits and usually cannot be billed on its own without a modifier override.

Medicare assigns 58562 a 000-day global period, so no post-operative visits are bundled and follow-up care is billed separately.

Practice management software like Pabau submits these claims through Claim.MD and checks each one for administrative completeness before it leaves the practice.

CPT Code 58562: official description and procedure overview

CPT Code 58562 describes hysteroscopy, surgical, with removal of impacted foreign body. The American Medical Association’s CPT code set places it in the surgical endoscopy/hysteroscopy family (58555-58565). The surgical action performed after the hysteroscope enters the uterine cavity defines each code in that family.

A standard operative hysteroscopy sequence guides the procedure covered by 58562. The surgeon dilates the cervix, installs distension media, and inserts the hysteroscope. Next, the surgeon visualizes the foreign body, works it free or fragments it, and extracts it. “Impacted” is the word that separates this code from simpler retrievals. It signals that the object took meaningful surgical effort to remove, beyond grasping and pulling.

Where 58562 sits among the other gynecologic surgical codes matters when one operative session involves multiple procedures. Medicare assigns the code a 000-day global period, which places it in the minor-procedure category rather than the major surgical package.

What qualifies as an impacted foreign body under CPT 58562

The term “impacted” is a clinical determination, not a coder’s call. The operative report must make the case, and payers review it closely on audit. These are the objects that often meet the threshold:

• Retained or embedded IUDs. A device whose arms have perforated or embedded into the myometrium counts. So does one whose strings are absent and that resists retrieval with a simple hook under direct visualization.
• Fragmented IUD components. A broken copper T-frame where one arm has separated and migrated within the endometrial cavity.
• Ossified fetal remnants. Calcified placental or fetal bone retained after a prior pregnancy, requiring hysteroscopic fragmentation before removal.
• Broken instrument fragments. Retained curette tips or other surgical debris from a prior procedure that cannot be retrieved without operative hysteroscopy.
• Other intrauterine objects. Retained suture material, Essure device fragments, or calcified tissue masses obstructing the cavity.

The key distinction is that “impacted” implies the object resists routine retrieval. A coder who sees “removed retained IUD” in the operative note, with no further description, should query the physician. That phrasing alone does not confirm the impacted threshold, so defaulting to 58562 is a risk.

Documentation the operative report must carry

Payers treat 58562 claims as audit targets because the “impacted” designation justifies a higher reimbursement than routine hysteroscopy. The operative report must contain all of the following to support the claim, and the absence of any single element is a common denial trigger.

• Approach confirmation. Explicit statement that the procedure was hysteroscopic, not laparoscopic or open. The place of service code (ASC vs. office) must match.
• Foreign body description. Identity of the object, its location within the uterine cavity, and the findings that established its impacted or embedded nature. For example: IUD arms embedded in posterior myometrium, strings absent on initial visualization.
• Surgical effort narrative. The instruments used, the technique applied (blunt dissection, electrosurgical release, mechanical fragmentation), and the number of passes or attempts required.
• Distension media and hysteroscope type. Fluid type, volume used, and deficit recorded (relevant for operative risk and anesthesia coding).
• Anesthesia type. General, MAC, or conscious sedation, since anesthesia coding (and the anesthesiologist’s claim) must align with the procedure complexity.
• Specimen handling. Whether the extracted object or tissue was sent to pathology.

The diagnosis code on the claim must also reflect the documented foreign body with the correct ICD-10-CM specificity. That includes the 7th character extension for encounter type, one of the clean claim submission requirements.

CPT 58562 vs. 58555, 58558, and 58561: how to choose the right code

The hysteroscopy family from 58555 to 58565 shares a common setup. What happens after the scope enters the cavity differentiates each code. One principle decides the choice every time. The most specific code that matches the documented procedure wins.

The decision tree is straightforward. If the object is biological tissue (polyp, fibroid), choose 58558 or 58561. If the object is non-biological and its removal required operative instrumentation beyond simple traction, CPT Code 58562 applies. A common error is using 58562 for any IUD removal, including those completed with a simple hook or forceps under direct visualization. That scenario may warrant 58558 or another code depending on the approach.

ICD-10 diagnosis codes that support the claim

Payers cross-reference the ICD-10-CM diagnosis code against the procedure code for medical necessity. A mismatched or vague diagnosis is one of the most preventable denial causes on 58562 claims. The rule is to use the most granular code the operative documentation supports.

The 7th character on T19 codes is a frequent claim rejection source. The first procedure for a given foreign body uses “A” (initial encounter). A follow-up visit for the same episode uses “D.” Using “D” on the initial operative claim, or mixing encounter types across related claims, triggers an instant edit at many clearinghouses. The T19 category follows the same 7th-character logic used across the injury and foreign body chapters. Verify the current ICD-10-CM tabular list each fiscal year, since code additions within T19 are possible at annual update.

Modifiers that apply, and when

Modifier selection on 58562 claims is an audit trigger. The AAPC Codify CPT lookup provides modifier guidance alongside code descriptors. Your billing team should consult the current NCCI edits table rather than relying on historical practice.

• Modifier 22 (Increased procedural complexity). Appropriate when the operative report documents unusual difficulty. Examples include a severely embedded IUD requiring myometrial dissection, extensive adhesions, or a fragmented device needing multiple passes. Requires a separate written narrative attached to the claim. The OIG flags modifier 22 as an overuse target. Apply it only where the documentation shows a level of service substantially above typical.
• Modifier 51 (Multiple procedures). Used when CPT Code 58562 is billed on the same claim as another surgical procedure. The second procedure sits at a different anatomical site or in a distinct operative session. The secondary procedure is reimbursed at 50% of the fee schedule amount.
• Modifier 52 (Reduced services). Rarely applicable to 58562; used when the procedure was terminated before full completion (e.g., equipment failure or patient safety concern requiring the surgeon to abort).
• Modifier 58 (Staged or related procedure). When 58562 is performed within the global period of a prior related surgical procedure as a planned staged procedure, not a complication.
• Modifier 59 (Distinct procedural service). Used to override an NCCI bundling edit when 58562 and another code are billed together as separate and distinct procedures. Payers scrutinize this modifier heavily on hysteroscopy claims.

NCCI bundling and what cannot be billed in the same session

The National Correct Coding Initiative bundles diagnostic endoscopy into surgical endoscopy of the same anatomical site. This directly affects 58562 claims when a diagnostic hysteroscopy (58555) was performed in the same session. That sequence is common, since surgeons confirm the foreign body location under direct visualization before operative removal.

Under standard NCCI logic, do not bill 58555 separately from CPT Code 58562 on the same date of service. The operative fee for 58562 is understood to include the diagnostic visualization. Submitting both without a modifier results in an instant bundling denial.

There is one exception. If the diagnostic hysteroscopy happened at a separate patient encounter, on a different date, 58555 is billable on its own for that date. Modifier 59 may override the NCCI edit where the procedures were distinctly separate in scope. Payers vary on whether they accept that override, and the documentation has to be unambiguous. Verify the current NCCI Procedure-to-Procedure edit table quarterly, as edit pairs update regularly.

Other codes often bundled with or mutually exclusive to CPT Code 58562 in the same session include 58558, 58561, and 58563. Sometimes a single session includes more than one hysteroscopic procedure, such as foreign body removal plus endometrial ablation. Select the primary procedure code and append modifier 51 to any extra procedure, where payer policy permits separate billing. Some commercial payers do not allow multiple hysteroscopy codes on the same date regardless of modifier.

Medicare reimbursement rates and RVUs

CMS calculates Medicare reimbursement for CPT Code 58562 from the Physician Fee Schedule, using RBRVS. The figures below are the CY2026 national non-facility and facility values from the CMS RVU file. Apply your geographic practice cost index (GPCI) in the CMS lookup tool, since it shifts payment by MAC jurisdiction.

CY2026 has two conversion factors, so the allowable depends on your billing entity. At $33.4009 (non-qualifying-APM), the non-facility total of 11.93 RVUs pays about $398; at $33.5675 (qualifying-APM), about $400. The facility total of 5.84 RVUs pays $195-$196 on the same two factors. The chart below shows which component separates the two settings.

Verify current RVU values and your geographic adjustment in the CMS lookup tool before quoting a figure. Pabau sends electronic claims through Claim.MD, which reaches thousands of US payers, with a maintained CPT catalog that keeps billing off a stale fee schedule.

Prior authorization requirements by payer type

Prior authorization requirements for CPT Code 58562 vary widely by payer and plan year. There is no universal rule, and stating otherwise creates compliance risk. The following framework reflects general industry patterns rather than a binding payer policy for any specific plan.

• Medicare. Traditional Medicare usually does not require prior authorization for operative hysteroscopy under the current PA program. Medicare Advantage plans operate under their own rules, and many do require authorization for surgical codes including 58562. Verify with the specific plan before scheduling.
• Medicaid. State Medicaid programs vary widely. Some states require authorization for all operative hysteroscopy; others have thresholds based on facility type or diagnosis. Check the specific state’s MAC or managed Medicaid plan policy.
• Commercial insurers. Many commercial carriers require prior authorization for elective operative hysteroscopy, whatever global period the code carries. A PA request for 58562 should include imaging evidence of the foreign body, such as an ultrasound confirming an embedded IUD. Add the operative indication and documentation of any failed outpatient retrieval attempt.

Tracking authorization status works at the point of scheduling rather than at the point of claim submission. A PA that expires between approval and the procedure date is a preventable denial.

Common denial reasons and how to appeal

CPT Code 58562 generates a higher denial rate than routine hysteroscopy codes because it requires documentation that specifically justifies the “impacted” classification. These are the most frequent denial categories and the corrective action for each.

• Missing or expired prior authorization. Correct action: Attach the original PA approval and evidence it was valid on the date of service. If PA was not obtained, file a retro-authorization request with the clinical documentation before appealing the denial.
• Diagnosis code mismatch. A T19 code submitted without the correct 7th character, or with T19.2 (vaginal foreign body) when the op report documents an intrauterine location, triggers CO-11. Correct action: Recode to the appropriate T19.8XXA, attach the operative report excerpt, and resubmit.
• Bundling denial (CO-97). Most commonly occurs when 58555 was billed alongside CPT Code 58562 on the same date. Correct action: Remove 58555 and resubmit, or attach documentation supporting a separate encounter and apply modifier 59 if justified.
• Insufficient documentation of impacted nature. The payer’s medical reviewer could not find language in the operative report establishing the object as impacted rather than routine. Correct action: Submit a written appeal with the operative note highlighted to show the specific documentation of embedding, adhesion, or fragmentation requiring operative instrumentation.
• Incorrect place of service code. Non-facility RVUs submitted with a facility POS code (or vice versa) trigger an edit. Correct action: Verify the POS code against the actual location and resubmit with the correct POS.

Sorting 58562 denials by CARC code and root cause exposes recurring patterns before they compound into revenue losses. The reference list of denial codes covers the CARC and RARC values that appear on hysteroscopy remittances. The AAPC CPT-to-ICD-10 crosswalk then lets billing staff confirm a medical necessity pairing before the claim reaches the payer.

Global period and post-operative billing

CPT Code 58562 carries a 000-day global period on the Medicare Physician Fee Schedule, with pre-operative, intra-operative, and post-operative percentages of 0.00. The allowable covers only the procedure and same-day services. No follow-up visits are bundled.

Billing teams that treat 58562 as a major surgical package leave money uncollected and append modifiers the code does not take. Here is what a 000-day designation carries.

• Bill post-operative visits on their own, as a standard E/M service at the documented level. No follow-up care sits inside the 58562 payment.
• Modifier 24 has no role. It releases an E/M service from a post-operative window, and a 000-day global has none. Appending it here only invites an edit.
• Modifiers 58, 78, and 79 have no role either. All three break a subsequent procedure out of a 010-day or 090-day package, and none applies to work after a 58562 claim.
• Same-day E/M uses modifier 25. Modifier 57, reserved for the decision-for-major-surgery visit, is the wrong choice here.
• Another code’s global period can still bind 58562, if the hysteroscopy falls inside the 090-day window of an earlier major surgery. Modifier 58, 78, or 79 then applies to the earlier procedure instead.
• Complications are billable services, such as a return to the operating room for bleeding or perforation, reported with the code that describes the work performed. No global-period modifier is needed.

CPT 58565, hysteroscopic sterilization by tubal implant, is the exception: it carries a 090-day global period and a larger non-facility practice expense. A practice billing both codes needs two sets of post-operative rules, so check the fee schedule to confirm which applies.

How claims software supports accurate 58562 billing

Billing accuracy on CPT Code 58562 depends on information flowing correctly from the operative report through to the claim. Practice management software built for gynecologic surgery works on that path at four points.

• A code library with current descriptors. A system that maintains current CPT descriptors keeps coders off stale reference data. It should flag when a code’s modifier requirements or global period designation change with the annual MPFS update.
• Eligibility checked before the visit. A real-time eligibility response at scheduling shows whether the plan is active and what it covers, which is where a PA conversation starts.
• Administrative completeness at claim creation. The system checks required fields, payer identifiers, place of service, and rendering provider before the claim goes out. A claim rejected on its format never reaches a reviewer.
• Electronic submission and status tracking. Claims leave through the clearinghouse and the acceptance, rejection, or payment message returns against the same patient record.

Pabau’s claims management software handles that administrative layer. Pabau checks claims for completeness, then submits them electronically to US payers through Claim.MD, with the status message coming back into the same record. The clinical judgment stays with the coder and the surgeon. That covers whether the object was impacted, which T19 character applies, and whether a modifier is defensible.

Keeping documentation, coding, and submission in one system removes the re-keying step. That step is where hysteroscopy codes and modifiers get lost between the operative note and the claim form.

Get hysteroscopy claims out clean the first time

Pabau checks each claim for administrative completeness, verifies eligibility before the visit, and submits electronically through Claim.MD. Claim status comes back into the same record your OB-GYN coders already work from.

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Conclusion

CPT Code 58562 has a narrow application. It covers hysteroscopic removal of a foreign body that required operative instrumentation rather than simple retrieval. The difference between a clean claim and a denial almost always traces back to the operative note. What matters is whether it documents the impacted nature of the object well enough to satisfy a payer’s medical reviewer.

Three habits raise first-pass acceptance on this code. Standardize the 58562 documentation checklist, map the correct T19 codes with accurate 7th characters, and check the NCCI table before a same-date pairing goes out. Those three stay with your coding team. Pabau handles the administrative half, from completeness checks and eligibility to electronic submission through Claim.MD. Book a demo to see that workflow applied to your own hysteroscopy volume.

Continue your research

Getting OB-GYN claims to US payers electronically? Claim.MD clearinghouse integration explains how Pabau submits claims and returns eligibility and status messages.

Coding a routine IUD removal instead? 58301 is the code for a removal that needs no operative hysteroscopy.

Was tissue removed rather than a device? 58558 is the biopsy and polypectomy code in the same hysteroscopy family.

Ablation performed in the same session? 58563 is bundled against 58562 in many payer policies, so read its rules before billing both.

Building the OB-GYN surgical superbill? Medical superbill guide covers how to structure a superbill for hysteroscopy procedures.

Frequently asked questions