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The CPT® Code 58262 refers to a surgical procedure known as a vaginal hysterectomy, specifically for the removal of a uterus weighing 250 grams or less, along with the removal of one or both fallopian tubes and/or ovaries. This procedure is typically indicated for various gynecological conditions that necessitate the removal of the uterus and associated reproductive structures. The process involves several critical steps, beginning with the placement of tenacula on the cervix to provide traction. The vaginal mucosa is then incised around the cervix, allowing access to the surrounding anatomical structures. Blunt and sharp dissection techniques are employed to separate the bladder from the uterus, ensuring that the bladder is elevated to expose the peritoneal vesicouterine fold, which is subsequently incised. The procedure continues with the exposure of the cul-de-sac and the broad ligament, where the uterosacral and cardinal ligaments are clamped, divided, and ligated to facilitate the removal of the uterus. The posterior uterine wall is grasped, and the uterus is delivered into the vagina. If the fallopian tubes and ovaries are to be removed, additional steps are taken to clamp and incise the tubo-ovarian round ligaments, followed by the transection of the fallopian tubes. The procedure concludes with the careful removal of the uterus, tubes, and ovaries, if applicable, and the management of any bleeding from the broad ligament. The peritoneum is then closed, and the vaginal cuff is left open to allow for drainage of the pelvis. This comprehensive description outlines the essential components of the procedure, emphasizing the surgical techniques and anatomical considerations involved in a vaginal hysterectomy with the removal of additional reproductive structures.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 58262 is indicated for various gynecological conditions that may require the removal of the uterus along with the fallopian tubes and/or ovaries. Common indications include:
The procedure for CPT® Code 58262 involves several detailed steps to ensure the safe and effective removal of the uterus, along with the tubes and/or ovaries. The steps are as follows:
Post-procedure care following a vaginal hysterectomy with the removal of tubes and/or ovaries includes monitoring for any signs of complications such as excessive bleeding or infection. Patients are typically advised to rest and avoid strenuous activities for a specified period to promote healing. Follow-up appointments are essential to assess recovery and address any concerns. The vaginal cuff is intentionally left open to facilitate drainage, which is a critical aspect of post-operative care to prevent fluid accumulation and potential infection. Patients may also receive guidance on managing pain and any other symptoms during their recovery period.
| Short Descr | VAG HYST INCLUDING T/O | Medium Descr | VAG HYST 250 GM/< W/RMVL TUBE&/OVARY | Long Descr | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) | 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) | 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. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1E - Major procedure - hysterctomy | MUE | 1 | CCS Clinical Classification | 124 - Hysterectomy, abdominal and vaginal |
| 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 | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 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. | 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. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 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). | AG | Primary physician | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Changed | Code description changed. |
| 1993-01-01 | Added | First appearance in code book in 1993. |
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