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Myomectomy is a surgical procedure aimed at the excision of fibroid tumors from the uterus. These fibroids, also known as myomas, are benign growths that develop in the muscle tissue of the uterus, specifically within the myometrium. They can vary in type based on their location: submucous fibroids grow into the uterine cavity, intramural fibroids are embedded within the uterine wall, subserous fibroids are located on the outer surface of the uterus, and pedunculated fibroids are attached to the uterus by a thin stalk. The procedure described by CPT® Code 58140 specifically addresses the removal of one to four intramural myomas, each with a total weight of 250 grams or less, as well as the removal of surface myomas. The surgical approach for this procedure is abdominal, which involves making an incision in the abdomen to access the uterus. Once the uterus is exposed, the surgeon inspects and palpates it to locate the fibroids. Depending on their type, the fibroids are either removed from the exterior or excised from within the uterine wall. The procedure is performed with careful attention to controlling bleeding, often utilizing electrocautery, and concludes with the layered suturing of the uterine wall. This surgical intervention is crucial for alleviating symptoms associated with fibroids, such as pelvic pain, heavy menstrual bleeding, and pressure symptoms, thereby improving the patient's quality of life.
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The myomectomy procedure described by CPT® Code 58140 is indicated for the following conditions:
The myomectomy procedure involves several key steps to ensure the effective removal of fibroid tumors:
Following the myomectomy procedure, patients can expect a recovery period that may involve monitoring for any complications such as bleeding or infection. Pain management will be provided as needed, and patients are typically advised to avoid strenuous activities for a specified period to allow for proper healing. Follow-up appointments will be necessary to assess recovery and ensure that the uterus is healing appropriately. Patients may also receive guidance on managing any symptoms related to fibroids that may persist post-surgery.
| Short Descr | MYOMECTOMY ABDOM METHOD | Medium Descr | MYOMECTOMY 1-4 MYOMAS W/250 GM/< ABDOMINAL APPR | Long Descr | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 125 - Other excision of cervix and uterus |
| 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). | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter |
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| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Changed | Code description changed. |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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