2025 CPT code 58180
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s).
Modifiers may be applicable depending on the circumstances of the procedure. For example, modifier 51 (Multiple Procedures) might be used if additional procedures are performed during the same session. Consult the CPT manual and NCCI edits for specific modifier guidelines.
Medical necessity for a supracervical hysterectomy is typically established in cases of significant uterine bleeding unresponsive to medical management, symptomatic fibroids, or severe pelvic pain related to endometriosis.The procedure must be deemed medically necessary by the attending physician and supported by appropriate documentation.
The physician performs the surgery under general anesthesia. This includes making the incision, dissecting the uterus, ligating blood vessels, removing the uterus (and other structures as indicated), and closing the incisions.
In simple words: The doctor removes the uterus through a cut in the abdomen, but leaves the cervix in place.Sometimes, the fallopian tubes and/or ovaries are also removed.
This procedure involves the removal of the uterus through an abdominal incision, while leaving the cervix intact.The fallopian tubes and/or ovaries may also be removed during the procedure. The surgeon makes a midline incision, enters the retroperitoneal space, and carefully dissects the uterus from surrounding structures, including the broad ligaments, round ligaments, ureters, and uterine arteries.The infundibulopelvic ligaments are cut if the ovaries are removed. The bladder is separated from the cervix, and the uterine arteries are clamped and cut. The fundus is separated from the cervix, and the uterus is removed. The endocervical tissue is often partially removed to reduce cancer risk. The remaining cervix is closed with sutures, and the abdominal wall is closed in layers.
Example 1: A 45-year-old woman with heavy menstrual bleeding undergoes a supracervical hysterectomy due to medical management failure. No other structures are removed., A 38-year-old woman with uterine fibroids causing significant pain and pressure undergoes a supracervical hysterectomy with bilateral salpingectomy (removal of fallopian tubes)., A 50-year-old woman with a history of endometriosis and severe pelvic pain undergoes a supracervical hysterectomy with bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries).
Complete medical history, physical examination findings,preoperative and postoperative diagnosis, operative report detailing the procedure performed, pathology report if any tissue is sent for analysis, and any relevant imaging studies.
** The description of "reverse conization" in the operative report does not require separate coding.
- Revenue Code: P1E (MAJOR PROCEDURE - HYSTERECTOMY)
- Payment Status: Active
- Modifier TC rule: The application of a Technical Component (TC) modifier depends on the specific billing arrangement between the surgeon and anesthesiologist.Consult with the billing department to determine appropriate modifier usage.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center