2025 CPT code 58542
Effective Date: N/A Surgery - Surgical Procedures on the Female Genital System Feed
Laparoscopic supracervical hysterectomy for a uterus weighing 250g or less; with removal of tube(s) and/or ovary(s).
Modifiers are applicable. Examples include 22 (Increased Procedural Services), 51 (Multiple Procedures), etc.Modifier 22 might be applicable in rare cases where the procedure is significantly more complex than usual, for example, extensive lysis of adhesions.
In simple words: The doctor removes the uterus, fallopian tubes, and ovaries through small incisions in the belly, using a camera and special tools. The cervix is left in place. The uterus is normal sized (less than 250 grams).
This code describes a procedure where the uterus, fallopian tubes, and ovaries are removed laparoscopically, preserving the cervix. The uterus is of normal size (250g or less). The procedure involves placing the patient in a dorsal lithotomy position, prepping and draping the abdomen, administering general anesthesia, and establishing pneumoperitoneum.Small incisions are made to insert trocars for visualization and instrument access. The bladder is dissected off the lower uterine segment, ureters are mobilized, and the broad ligament is opened. The infundibulopelvic ligaments are incised to remove the ovaries.The uterine attachments (round ligaments) are incised, and any present fibroids are removed or tagged. The uterine artery is identified, incised, and clamped. The fundus of the uterus is separated from the cervix, and any bleeding from the cervical stump is addressed. A morcellator is used to remove the uterus in small pieces. Finally, the abdomen is deflated, incisions are closed, and the instruments are removed.
Example 1: A 45-year-old woman with symptomatic uterine fibroids and menorrhagia undergoes a laparoscopic supracervical hysterectomy with removal of tubes and ovaries. The uterus weighs 200g., A 50-year-old woman with a family history of ovarian cancer elects to have a prophylactic laparoscopic supracervical hysterectomy with bilateral salpingo-oophorectomy. Her uterus is normal size., A 38-year-old woman with chronic pelvic pain undergoes laparoscopic supracervical hysterectomy, bilateral salpingectomy, and left oophorectomy due to a large endometrioma in the left ovary. The uterus weighs 180g.
Operative report detailing the procedure, including size of the uterus, removal of tubes and/or ovaries, any complications, and any additional procedures performed. Pre-operative imaging and diagnostic reports supporting the medical necessity of the procedure should also be documented.
- Specialties:Obstetrics and Gynecology, Gynecologic Oncology
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital