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2025 CPT code 58544

Laparoscopic supracervical hysterectomy for a uterus weighing over 250g, including removal of fallopian tubes and/or ovaries.

Surgical laparoscopy always includes diagnostic laparoscopy.Use 49320 for a separate diagnostic laparoscopy (peritoneoscopy) and 58555 for a separate diagnostic hysteroscopy.

Modifiers may be applicable depending on the circumstances of the procedure (e.g., 59 for a distinct procedural service, 80 for an assistant surgeon).Consult the CPT manual and payer guidelines for specific modifier usage.

Medical necessity for a supracervical hysterectomy is typically established by symptoms such as heavy menstrual bleeding (menorrhagia), chronic pelvic pain, abnormal uterine bleeding,or uterine fibroids significantly impacting quality of life. The size of the uterus exceeding 250g in this code implies significant uterine enlargement warranting the procedure.

A gynecologist or surgeon performs this procedure. The clinical responsibilities include pre-operative assessment, obtaining informed consent, performing the surgical procedure with appropriate care, post-operative monitoring, and providing follow-up care.

IMPORTANT:Code 58543 describes a similar procedure but without the removal of the fallopian tubes and/or ovaries. Code 58542 is used for a supracervical hysterectomy with or without removal of tubes/ovaries when the uterus weighs 250g or less.

In simple words: This code describes a minimally invasive surgery to remove the uterus (leaving the cervix), fallopian tubes, and/or ovaries.The surgery uses small cuts and a camera to guide the instruments.It is used when the uterus is larger than usual.

This CPT code represents a laparoscopic surgical procedure involving the removal of the uterus (hysterectomy), leaving the cervix intact (supracervical).The procedure is performed laparoscopically, utilizing small incisions and a laparoscope.This specific code applies when the uterus weighs more than 250 grams.The procedure also includes the removal of one or both fallopian tubes and/or ovaries.The procedure involves several steps: prepping and draping the abdomen, creating a pneumoperitoneum,making small incisions to insert trocars, dissecting the bladder, identifying and ligating the ureters and infundibulopelvic ligaments, removing the ovaries, cutting the uterine attachments, removing the uterus (potentially using a morcellator), and closing the incisions. Robotic-assisted laparoscopy may be employed.

Example 1: A 45-year-old woman presents with heavy menstrual bleeding and uterine fibroids, with a uterine weight estimated to be 300g.A laparoscopic supracervical hysterectomy with bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries) is performed using code 58544., A 38-year-old woman with endometriosis and a large uterus (over 250g) undergoes a laparoscopic supracervical hysterectomy with removal of the right fallopian tube and ovary due to significant disease in that area., A 50-year-old woman experiencing significant menorrhagia and a large fibroid uterus (weight over 250g) elects to undergo a laparoscopic supracervical hysterectomy with removal of only the fallopian tubes.

** The weight of the uterus is a crucial factor in selecting the appropriate code.Accurate documentation of the weight and any other relevant findings is essential for correct coding and reimbursement.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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iFrame™ AI's knowledge is aligned with and limited to the materials uploaded by users and should not be interpreted as medical, legal, or any other form of advice by iFrame™.