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The procedure described by CPT® Code 58553 refers to a laparoscopic surgical technique that involves performing a vaginal hysterectomy on a uterus that weighs more than 250 grams. This minimally invasive approach begins with the creation of a small incision just below the umbilicus, through which a trocar is inserted to allow for the introduction of a laparoscope. The laparoscope is a specialized instrument equipped with a camera that provides visual access to the abdominal cavity and the uterus, enabling the surgeon to inspect these areas thoroughly. To facilitate the surgical procedure, two or three additional portal incisions are made in the lower abdomen for the insertion of various surgical instruments. During the operation, bipolar coagulation is utilized to manage bleeding effectively. The surgeon transects the round ligaments and subsequently the broad ligament, which are essential structures supporting the uterus. To elevate the vaginal apex, ring forceps are employed while the bladder flap is developed through both blunt and sharp dissection techniques. The procedure continues with the coagulation and transection of the bladder pillars, followed by the development of the perivesical and perivaginal spaces, again using both blunt and sharp dissection methods. A linear stapler is then used to transect either the infundibulopelvic or utero-ovarian ligaments, depending on whether the surgical plan includes the removal of the fallopian tubes and/or ovaries. The ascending branch of the uterine artery is also transected to ensure proper blood flow management. A circular incision is made in the upper aspect of the vaginal wall to access the cardinal ligament, which is approached vaginally, cross-clamped, divided, and ligated with sutures. The uterus is then delivered through the vaginal incision and removed. If necessary, techniques such as wedge morcellation, coring, or bivalving may be employed to facilitate the removal of the uterus. Finally, the peritoneum and vaginal cuff are closed, and the abdomen is inspected laparoscopically to ensure there is no residual bleeding, which is controlled using laser cautery if needed. The abdomen is irrigated, instruments are removed, and the portal incisions are closed. It is important to note that this code is specifically used for laparoscopic-assisted vaginal hysterectomy (LAVH) without the removal of tubes and/or ovaries, while a different code (CPT® Code 58554) is designated for cases where the tubes and/or ovaries are removed.
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The laparoscopic surgical procedure described by CPT® Code 58553 is indicated for patients presenting with a uterus that exceeds 250 grams in weight. This condition may arise due to various gynecological issues, including but not limited to uterine fibroids, abnormal uterine bleeding, or other pathologies that necessitate the removal of the uterus. The procedure is typically considered when conservative management options have been exhausted or are deemed inappropriate, and the patient is experiencing significant symptoms that impact their quality of life.
The laparoscopic surgical procedure begins with the creation of a small incision just below the umbilicus, where a trocar is inserted to allow access to the abdominal cavity. The laparoscope is then introduced through this trocar, providing visual inspection of the abdominal cavity and the uterus. Following this initial step, two or three additional portal incisions are made in the lower abdomen to facilitate the introduction of surgical instruments necessary for the procedure.
Post-procedure care following a laparoscopic-assisted vaginal hysterectomy (LAVH) includes monitoring the patient for any signs of complications such as bleeding or infection. Patients are typically advised to rest and may be prescribed pain management medications to alleviate discomfort. Recovery time can vary, but many patients can expect to resume normal activities within a few weeks, depending on their overall health and the specifics of the surgery. Follow-up appointments are essential to ensure proper healing and to address any concerns that may arise during the recovery process. Patients should be educated on signs of complications, such as excessive bleeding, fever, or unusual pain, and instructed to seek medical attention if these occur.
| Short Descr | LAPARO-VAG HYST COMPLEX | Medium Descr | LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS | Long Descr | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; | 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 |
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) |
| 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. | 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 |
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| 2011-01-01 | Changed | Short description changed. |
| 2010-01-01 | Changed | Code description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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