2025 CPT code 58541
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Female Genital System - Laparoscopic Hysterectomy Surgery Feed
Laparoscopic surgical supracervical hysterectomy for a uterus weighing 250g or less.
Modifiers such as 59 (distinct procedural service), 22 (increased procedural service), and others may be applicable depending on the specific circumstances of the procedure. Consult the CPT manual and payer-specific guidelines.
Medical necessity for a supracervical hysterectomy is generally established by symptoms such as heavy menstrual bleeding (menorrhagia), abnormal uterine bleeding, uterine fibroids causing pain or pressure, endometriosis, or adenomyosis. The decision to proceed is based on clinical judgement and the patient's preferences after appropriate discussion of alternatives.
The clinical responsibility includes preoperative evaluation, informed consent,performing the laparoscopic supracervical hysterectomy, managing any complications, providing postoperative care and follow-up.
In simple words: This code describes a minimally invasive surgery to remove the uterus (womb) through small incisions in the abdomen using a camera and special tools.The cervix (lower part of the uterus) and other reproductive organs are left in place. This procedure is used when the uterus is a normal size.
This CPT code encompasses a laparoscopic surgical procedure involving the removal of the uterus (hysterectomy) while preserving the cervix, fallopian tubes, and ovaries.The procedure is specifically for uteri weighing 250 grams or less. The technique involves the use of a laparoscope, small incisions, and specialized instruments to access and remove the uterus.The procedure may be performed using robotic assistance.
Example 1: A 45-year-old female patient presents with heavy menstrual bleeding and uterine fibroids.A laparoscopic supracervical hysterectomy (58541) is performed to alleviate her symptoms.The uterus weighs 200g., A 38-year-old patient with endometriosis experiences chronic pelvic pain. A laparoscopic supracervical hysterectomy (58541) is performed to reduce pain. The uterus is 220g., A 50-year-old patient undergoing a laparoscopic supracervical hysterectomy (58541) for abnormal uterine bleeding also has a concurrent laparoscopic removal of an ovarian cyst.Modifier 59 may be required in this scenario.
Complete history and physical examination, documentation of the indication for the hysterectomy, operative report detailing the procedure, pathology report confirming the removal of the uterus and its weight, postoperative orders, and patient follow-up notes. Preoperative imaging (ultrasound) to assess uterine size and characteristics.
** The weight of the uterus is a critical factor in selecting the appropriate code.Accurate weight documentation is essential for accurate billing.The use of robotic assistance is not separately coded.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: This information is not available in the provided sources.Consult the current year's Medicare Physician Fee Schedule for RVU values and reimbursement rates.
- Global Days: The global period for this procedure varies depending on payer and local regulations. It is typically several days post-op.Consult the specific payer's guidelines for accurate information.
- Payment Status: Active
- Modifier TC rule: This code may allow for the application of a Technical Component (TC) modifier in certain situations, depending on the billing arrangements and payer guidelines.
- Fee Schedule: Fee schedule data is not provided in the sources. Consult fee schedules from payers such as Medicare and private insurers for historical and current rates.
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient and Outpatient)