© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 58554 refers to a laparoscopic surgical technique that involves the removal of the uterus, along with the potential removal of one or both fallopian tubes and/or ovaries. This procedure is specifically indicated for cases where the uterus weighs more than 250 grams, which may be due to conditions such as fibroids or other abnormalities. The laparoscopic approach is minimally invasive, utilizing small incisions in the abdomen to insert a laparoscope and surgical instruments, allowing for visual inspection and manipulation of the abdominal cavity and reproductive organs. The procedure begins with the placement of a trocar below the umbilicus, followed by the introduction of the laparoscope to visualize the internal structures. Multiple portal incisions are made to facilitate the use of surgical instruments. The surgical steps include the transection of ligaments, dissection of surrounding tissues, and careful removal of the uterus through a vaginal incision. This method aims to minimize recovery time and postoperative complications compared to traditional open surgery, while effectively addressing the medical needs of the patient.
© Copyright 2025 Coding Ahead. All rights reserved.
The laparoscopic surgical procedure described by CPT® Code 58554 is indicated for the following conditions:
The laparoscopic surgical procedure involves several detailed steps to ensure the safe and effective removal of the uterus and associated structures:
After the completion of the laparoscopic surgical procedure, patients can expect a recovery period that may vary based on individual health factors and the extent of the surgery performed. Post-procedure care typically includes monitoring for any signs of complications, such as bleeding or infection. Patients may be advised to rest and gradually resume normal activities, with specific instructions regarding pain management and follow-up appointments. It is essential to follow the surgeon's recommendations for post-operative care to ensure optimal recovery and healing.
| Short Descr | LAPARO-VAG HYST W/T/O COMPL | Medium Descr | LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR | Long Descr | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; 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 |
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). | 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. | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
Get instant expert-level medical coding assistance.