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The procedure described by CPT® Code 58545 refers to a laparoscopic surgical technique known as myomectomy, specifically the excision of one to four intramural myomas, which are benign tumors located within the muscle tissue of the uterus (myometrium). This procedure may also involve the removal of surface myomas, which can be subserous or pedunculated. Uterine fibroids, or myomas, are non-cancerous growths that can vary in type and location; they may protrude into the uterine cavity (submucous), be embedded within the uterine wall (intramural), or be located on the outer surface of the uterus (subserous). The laparoscopic approach allows for minimally invasive surgery, which typically results in reduced recovery time and less postoperative pain compared to traditional open surgery. During the procedure, the surgeon makes a small incision below the umbilicus to insert a trocar and laparoscope, enabling visual inspection of the uterus to locate the fibroids. Additional incisions are made to introduce surgical instruments for the excision of the fibroids. The technique involves careful dissection and removal of the fibroids while controlling bleeding, often using electrocautery, and ultimately repairing the uterus in layers. This code is specifically applicable when the total weight of the excised myomas does not exceed 250 grams, and it is important to differentiate it from CPT® Code 58546, which is used for the removal of five or more myomas or those exceeding the specified weight limit.
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The laparoscopic myomectomy procedure described by CPT® Code 58545 is indicated for the surgical removal of uterine fibroids, specifically when the following conditions are present:
The laparoscopic myomectomy procedure involves several key steps to ensure the effective removal of myomas:
Following the laparoscopic myomectomy, patients can expect a recovery period that typically involves monitoring for any complications such as bleeding or infection. Pain management is an important aspect of post-operative care, and patients may be prescribed analgesics to manage discomfort. Most patients are advised to avoid strenuous activities and heavy lifting for a specified period to allow for proper healing. Follow-up appointments are essential to assess recovery and ensure that the uterus is healing appropriately. Patients should also be informed about potential changes in menstrual patterns following the procedure, as well as the possibility of fibroid recurrence.
| Short Descr | LAPAROSCOPIC MYOMECTOMY | Medium Descr | LAPS MYOMECTOMY EXC 1-4 MYOMAS 250 GM/< | Long Descr | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas | 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 | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 125 - Other excision of cervix and uterus |
This is a primary code that can be used with these additional add-on codes.
| 49327 | Addon Code MPFS Status: Active Code APC N ASC N1 Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure) |
| 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. | 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.) | 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 | LT | Left side (used to identify procedures performed on the left side of the body) | SG | Ambulatory surgical center (asc) facility service | 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 | Added | First appearance in code book in 2003. |
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