2025 CPT code 58262
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Vaginal hysterectomy for a uterus weighing 250 grams or less, with removal of tubes and/or ovaries.
Modifiers may be applicable depending on the circumstances of the procedure. Consult the CPT codebook and your payer's guidelines for details on modifier use.
Medical necessity is established when conservative management of a condition has failed or when a patient's symptoms and quality of life are significantly impaired. This code should only be used when the uterus meets the size criteria and the vaginal approach is feasible.Documentation should justify the medical necessity for the hysterectomy.
The physician performs the entire surgical procedure, including pre-operative assessment, anesthesia administration (if applicable), surgical excision, and post-operative care. This includes meticulous dissection and hemostasis to minimize blood loss and complications.The surgeon is responsible for ensuring the patient's safety and well-being throughout the procedure.
In simple words: This surgery removes the uterus, cervix, fallopian tubes, and ovaries through the vagina. It's done for uteruses of normal size and typically involves a smaller incision and faster recovery than other hysterectomy types.
This procedure involves the surgical removal of the uterus, cervix, fallopian tubes, and ovaries through a vaginal approach.The procedure is performed on a uterus of normal size (250 grams or less). The patient is placed in the dorsal lithotomy position under general anesthesia. The provider examines the genital tract, inserts a weighted speculum, and injects a local anesthetic into the cervix and surrounding tissue.The uterosacral and cardinal ligaments are incised near the cervix, then sutured to the posterior vaginal walls for vaginal support. The anterior vaginal wall is incised to free the bladder, and the uterine arteries are clamped and incised. The broad ligament is elevated to incise the infundibulopelvic and round ligaments, releasing the ovaries and uterus. The uterus (≤250g), cervix, fallopian tubes, and ovaries are removed. The vaginal cuff is suspended by suturing it to the uterosacral and cardinal ligaments, and the uterosacral ligaments are pleated to prevent bowel prolapse. Finally, the vaginal cuff is closed with sutures.
Example 1: A 45-year-old woman with menorrhagia (heavy menstrual bleeding) unresponsive to medical management undergoes a total vaginal hysterectomy with bilateral salpingo-oophorectomy (TVH+BSO) due to a normal-sized uterus., A 38-year-old woman with symptomatic uterine fibroids and a normal-sized uterus undergoes a total vaginal hysterectomy (TVH) with removal of the tubes and ovaries., A 50-year-old woman presents with uterine prolapse and undergoes a total vaginal hysterectomy to correct the prolapse. Her ovaries and tubes are left in situ.
* Complete history and physical examination.* Documentation of medical necessity (e.g., failed conservative management for menorrhagia, symptomatic fibroids).* Pre-operative imaging (ultrasound, if indicated).* Operative report detailing the procedure and findings.* Pathology report confirming the nature of any tissue removed.* Post-operative progress notes and discharge summary.
** This code specifically applies to vaginal hysterectomies where the uterus weighs 250 grams or less.Larger uteruses typically require a different surgical approach and code.The removal of fallopian tubes and/or ovaries is included in the code.Always refer to the most up-to-date CPT manual for accurate coding.
- Revenue Code: P1E (MAJOR PROCEDURE - HYSTERECTOMY)
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier would not typically be used with this code as it represents a complete surgical procedure.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Office