2025 CPT code 58140
Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach.
Modifiers may be applicable to 58140. Modifier 22 (Increased Procedural Services) may be used if the procedure is significantly more complex than usual due to factors such as extensive adhesions, large or numerous fibroids requiring significant dissection, or unexpected intraoperative complications. Modifier 52 (Reduced Services) may be used if the procedure is intentionally shortened or terminated due to circumstances beyond the surgeon's control.
Medical necessity for 58140 is established when the patient experiences significant symptoms attributable to uterine fibroids, such as heavy menstrual bleeding, pelvic pain and pressure, or infertility.The size, number, and location of the fibroids should be documented and correlate with the patient's symptoms.Conservative management options should have been tried or considered unsuitable before surgery is recommended.
The physician is responsible for the complete surgical management of the patient, including preoperative evaluation, intraoperative performance of the myomectomy, and postoperative care. This includes patient positioning, anesthesia administration, surgical technique, bleeding control, and wound closure.
In simple words: This procedure removes one to four non-cancerous fibroid tumors from the uterus through a cut in the belly. The fibroids are usually inside the uterine wall or on the surface and weigh less than 250 grams. This surgery allows women to keep their uterus and may improve their chances of getting pregnant.
This procedure involves the removal of one to four fibroid tumors from the uterus through an abdominal incision. The total weight of the intramural myomas must be 250 grams or less. Surface myomas can also be removed regardless of their number. The procedure is performed under general anesthesia with the patient in the supine position.The surgeon makes an incision in the abdomen to expose the uterus. After locating the fibroids (which can be on the surface of the uterus or just beneath it), the surgeon excises them.The uterine defects resulting from the removal are then sutured, bleeding is controlled, and the abdominal incision is closed.
Example 1: A 35-year-old woman experiencing heavy menstrual bleeding and pelvic pain is diagnosed with two intramural fibroids weighing a total of 150 grams. She desires to preserve her fertility and undergoes an abdominal myomectomy (58140)., A 40-year-old woman with three small surface fibroids and one intramural fibroid weighing 100 grams is experiencing discomfort and bladder pressure.She undergoes an abdominal myomectomy to remove all four fibroids (58140)., A 32-year-old woman has been trying to conceive for a year without success.An ultrasound reveals two small intramural fibroids totaling 80 grams, believed to be contributing to her infertility. She undergoes an abdominal myomectomy (58140) to improve her chances of pregnancy.
Documentation should include the number, size, location (intramural or surface), and total weight of fibroids removed. Operative notes should detail the surgical approach, technique, any complications encountered, and estimated blood loss. Preoperative imaging reports (e.g., ultrasound) confirming the presence and characteristics of the fibroids are also necessary.
- Revenue Code: P1G
- Specialties:Obstetrics and Gynecology, Gynecologic Oncology, General Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center