2025 CPT code 58548
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Laparoscopic radical hysterectomy with bilateral pelvic and para-aortic lymph node sampling, including fallopian tube and ovary removal if performed.
Modifiers may apply depending on the circumstances of the procedure. Consult the CPT manual and payer guidelines for appropriate modifier usage.
Medical necessity for a radical hysterectomy is typically established in cases of early-stage cervical cancer, endometrial cancer, or certain types of ovarian cancer.The extent of lymph node dissection depends on the stage and location of the cancer.Appropriate imaging and pathology are critical to determine the appropriate procedure and code.
The procedure is performed by a gynecological surgeon or a surgeon qualified in performing complex laparoscopic surgeries. This requires extensive surgical training in pelvic anatomy and oncologic surgery.
In simple words: The doctor removes the uterus, cervix, and nearby tissues through small incisions in the abdomen using a laparoscope (a thin tube with a camera).Lymph nodes in the pelvis and abdomen are also removed and checked for cancer. The fallopian tubes and ovaries may also be removed.
This procedure involves a laparoscopic surgical approach to remove the uterus, cervix, parametrium, cardinal and uterosacral ligaments, and bilateral pelvic lymph nodes.Para-aortic lymph node sampling is also conducted.The fallopian tubes and ovaries are removed if indicated. The procedure includes meticulous dissection and hemostasis, and closure of all incisions.
Example 1: A 45-year-old female presents with abnormal uterine bleeding and a suspicious pelvic mass on ultrasound.A laparoscopic radical hysterectomy with bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries) and lymphadenectomy is performed. Pathology confirms endometrial cancer, stage IB., A 50-year-old female with a history of cervical cancer undergoes a laparoscopic radical hysterectomy with pelvic and para-aortic lymph node dissection for suspected recurrence. Post-operative pathology is negative for cancer recurrence., A 38-year-old female with early-stage ovarian cancer undergoes a laparoscopic radical hysterectomy (including bilateral salpingo-oophorectomy) and lymphadenectomy for optimal staging and cytoreduction.
* Pre-operative diagnosis and imaging studies (ultrasound, CT scan, MRI).* Operative report detailing the extent of the procedure, lymph node retrieval, and specimen description.* Pathology report confirming the diagnosis and staging.* Post-operative notes documenting recovery and complications.* Medical necessity documentation supporting the need for a radical hysterectomy.
** This code describes a complex surgical procedure requiring significant surgical expertise.The specific details of the procedure (e.g., extent of lymph node dissection, removal of adnexa) should be clearly documented in the operative report to ensure accurate coding and reimbursement.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: This information is not available in the provided sources and requires accessing a specific Relative Value Unit (RVU) database for the current year. RVUs vary based on geographic location and payer.
- Global Days: The global period for this procedure would need to be determined based on the specific payer and their guidelines.It typically involves a postoperative period of several days to weeks.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier may be applicable, depending on the specific services rendered and who performed them (surgeon vs. assistant).
- Fee Schedule: Historical fee schedule data is not available within the provided source. This information would need to be obtained from a historical fee schedule database specific to the payer and geographic location.
- Specialties:Obstetrics and Gynecology, Gynecologic Oncology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center