2025 CPT code 58270
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Vaginal hysterectomy for uterus ≤250g; with enterocele repair.
Modifiers may be applicable depending on the circumstances, such as 51 for multiple procedures if another procedure is performed at the same time, or 22 for increased procedural services if unusual circumstances increased the complexity of the procedure. Consult the CPT manual and payer-specific guidelines for accurate modifier application.
Medical necessity for a vaginal hysterectomy with enterocele repair is established by clinical symptoms such as menorrhagia, pelvic pressure or pain, prolapse symptoms, and the presence of an enterocele. The weight of the uterus must also meet the criteria specified (≤250g).
The physician performs the entire procedure, including pre-operative examination, administration of anesthesia (if applicable), surgical removal of the uterus and cervix, repair of the enterocele, and post-operative care.
In simple words: This surgery removes the uterus and cervix through the vagina.It also fixes a small bowel bulge into the vagina.This is done under general anesthesia. The doctor will make incisions, remove the uterus and cervix, and repair the bulge.
This procedure involves the surgical removal of the uterus and cervix via a vaginal approach (vaginal hysterectomy) where the uterus weighs 250 grams or less.It also includes the repair of an enterocele, a prolapse of the small bowel into the vaginal canal. The procedure begins with placing the patient in the dorsal lithotomy position under general anesthesia.The provider examines the genital tract, then uses a weighted speculum to access the vagina and injects a numbing agent into the cervix and surrounding tissue.The uterus is freed from its attachments (uterosacral, cardinal, ovarian, and round ligaments), the uterine arteries are clamped and incised, and the uterus and cervix are removed. The enterocele is opened, the bowel is repositioned, the sac is closed, excess tissue is removed, and the vaginal cuff is repaired.The uterosacral and cardinal ligaments may be suspended and pleated for added support.
Example 1: A 45-year-old female presents with menorrhagia and pelvic pressure.A vaginal hysterectomy with enterocele repair (58270) is performed due to uterine fibroids and a small bowel prolapse., A 50-year-old female patient undergoes a vaginal hysterectomy (58270) for symptomatic uterine prolapse and concurrent enterocele.The uterus is less than 250 grams., A 60-year-old woman presents post-partum with a large enterocele and a small, atrophied uterus weighing 150g. The physician chooses to perform a vaginal hysterectomy (58270) to address both issues simultaneously.
* Pre-operative assessment including patient history, physical examination, imaging studies (if any), and informed consent.* Operative report detailing the surgical technique, including the weight of the uterus, the type of enterocele repair, and any complications.* Pathology report confirming the diagnosis and findings related to the removed uterus.* Post-operative notes, including recovery progress, discharge instructions and any follow up care.
** This code is specifically for vaginal hysterectomy when the uterus is 250 grams or less and requires concurrent enterocele repair. If the uterus is larger, or other procedures are performed, different codes may apply.
- Revenue Code: P1E (MAJOR PROCEDURE - HYSTERECTOMY)
- Payment Status: Active
- Modifier TC rule: Not applicable
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Hospital Outpatient