© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 58263 refers to a surgical procedure known as a vaginal hysterectomy, specifically for a uterus weighing 250 grams or less. This procedure involves the removal of the uterus along with the associated fallopian tubes and/or ovaries, and it includes the repair of an enterocele, which is a type of hernia that occurs in the pelvic region. The procedure is performed through the vaginal canal, utilizing various surgical techniques to ensure the safe and effective removal of the reproductive organs while addressing any complications such as an enterocele. The process begins with the placement of tenacula on the cervix to provide traction, followed by an incision of the vaginal mucosa around the cervix. The bladder is then carefully separated from the uterus using both blunt and sharp dissection techniques. This meticulous approach allows for the elevation of the bladder and exposure of the peritoneal vesicouterine fold, which is subsequently incised to facilitate access to the pelvic cavity. The procedure continues with the clamping and division of the uterosacral and cardinal ligaments, leading to the delivery of the uterus into the vagina. If necessary, the fallopian tubes and ovaries are also removed during this procedure. The enterocele repair involves opening the vaginal mucosa over the enterocele, dissecting the perirectal fascia, and closing the sac with sutures after repositioning the small bowel. This comprehensive description highlights the complexity and precision required in performing a vaginal hysterectomy with enterocele repair, ensuring that all anatomical structures are handled with care to promote optimal patient outcomes.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 58263 is indicated for patients presenting with specific conditions that necessitate the removal of the uterus, fallopian tubes, and/or ovaries, along with the repair of an enterocele. The following are the explicitly provided indications for this surgical intervention:
The surgical procedure associated with CPT® Code 58263 involves several critical steps, each designed to ensure the safe and effective removal of the uterus, tubes, and ovaries, while also addressing the enterocele. The following procedural steps are outlined:
Post-procedure care following a vaginal hysterectomy with enterocele repair involves monitoring the patient for any signs of complications, such as 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 ensure that the surgical site is healing properly. Additionally, patients may receive instructions regarding pain management and any necessary lifestyle modifications to support their recovery process.
| Short Descr | VAG HYST W/T/O & VAG REPAIR | Medium Descr | VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL | Long Descr | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele | 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 | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1E - Major procedure - hysterctomy | MUE | 1 | CCS Clinical Classification | 124 - Hysterectomy, abdominal and vaginal |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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). | AG | Primary physician | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | KX | Requirements specified in the medical policy have been met | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 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. |
Get instant expert-level medical coding assistance.