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The procedure described by CPT® Code 58552 involves a laparoscopically assisted vaginal hysterectomy (LAVH) performed on a uterus that weighs 250 grams or less. This surgical technique combines the use of laparoscopic instruments with traditional vaginal surgery to remove the uterus, and it may also include the removal of one or both fallopian tubes and/or ovaries. The procedure begins with the creation of a small incision below the umbilicus, through which a trocar is inserted to allow for the introduction of a laparoscope. This instrument provides the surgeon with a visual guide to inspect the abdominal cavity and the uterus. Additional small incisions are made in the lower abdomen to facilitate the insertion of surgical instruments necessary for the operation. During the procedure, the surgeon employs bipolar coagulation to manage bleeding while transecting the round ligaments and broad ligament. The vaginal apex is elevated using ring forceps, and the bladder flap is developed through careful dissection. The procedure continues with the coagulation and transection of the bladder pillars, followed by the development of the perivesical and perivaginal spaces. A linear stapler is utilized to transect the infundibulopelvic or utero-ovarian ligaments, depending on whether the tubes and/or ovaries are being excised. The ascending branch of the uterine artery is also transected, and an incision is made in the upper aspect of the vaginal wall. The cardinal ligament is accessed vaginally, clamped, divided, and ligated with sutures. The uterus is then delivered through the vaginal incision and removed, after which the vaginal cuff is closed. The laparoscopic inspection of the abdomen is performed to ensure there is no bleeding, which is controlled if necessary using laser cautery. Finally, the abdomen is irrigated, instruments are withdrawn, and the portal incisions are closed. This procedure is distinct from CPT® Code 58550, which is used when the LAVH is performed without the removal of tubes and/or ovaries.
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The procedure described by CPT® Code 58552 is indicated for the surgical treatment of conditions related to the uterus, particularly when the uterus weighs 250 grams or less. The following conditions may warrant this procedure:
The laparoscopically assisted vaginal hysterectomy (LAVH) procedure involves several key steps, each critical to the successful removal of the uterus and any associated structures. The procedure begins with the surgeon making a small incision just below the umbilicus, through which a trocar is inserted to allow for the introduction of a laparoscope. This instrument provides visualization of the abdominal cavity and the uterus. Following this, two or three additional portal incisions are made in the lower abdomen to facilitate the insertion of surgical instruments necessary for the operation.
After the completion of the laparoscopically assisted vaginal hysterectomy, patients are typically monitored for any immediate complications. Post-procedure care may include pain management, monitoring for signs of infection, and ensuring proper healing of the surgical sites. Patients are usually advised on activity restrictions, including avoiding heavy lifting and strenuous exercise for a specified period. Follow-up appointments are essential to assess recovery and address any concerns that may arise during the healing process. The expected recovery time may vary, but many patients can return to normal activities within a few weeks, depending on individual circumstances and the extent of the surgery performed.
| Short Descr | LAPARO-VAG HYST INCL T/O | Medium Descr | LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES | Long Descr | Laparoscopy, surgical, with 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 124 - Hysterectomy, abdominal and vaginal |
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) |
| 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure 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 | 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). | 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. | 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.) | 81 | Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. | 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 | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | 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 |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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