2025 CPT code 58150
Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Feed
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s).
Modifier 22 can be appended if the documentation supports significant additional work, such as the presence of large fibroids. If a pelvic mass not attached to the uterus is also removed, codes 49203–49205 can be used additionally.
Medical necessity must be established based on the patient's specific diagnosis and the clinical rationale for performing a hysterectomy. Common indications include uterine fibroids, endometriosis, abnormal uterine bleeding, pelvic pain, and gynecologic cancers.
In simple words: The doctor removes the uterus and cervix through a cut in the belly. The fallopian tubes and ovaries might also be removed. The woman is lying on her back for the surgery and is asleep from anesthesia. The doctor makes a cut in the belly, finds the uterus, and carefully detaches it from surrounding tissues and blood vessels. The opening of the vagina is then stitched closed, and the cut in the belly is also closed.
This procedure involves the removal of the uterus and cervix through an abdominal incision. The fallopian tubes and ovaries may also be removed, either totally or partially. The procedure begins with the patient in the supine position under general anesthesia. A midline incision is made into the abdominal wall, and the abdominal cavity is explored. The uterus is grasped, and the round ligaments are cut and separated. The broad ligament is incised to loosen the area around the uterus. The ureters are identified and moved away from the uterus. If the fallopian tubes and ovaries are to be removed, the infundibulopelvic ligaments are cut. Otherwise, the fallopian tubes and ovarian ligaments are cut close to the uterus. The bladder is detached from the cervix. The uterine artery is clamped, cut, sutured, and ligated. The cardinal and uterosacral ligaments are similarly treated, and the uterosacral ligament is anchored to the cardinal ligament. The vagina is incised circularly, and the uterus, along with the cervix and any other removed organs, is removed. The vaginal cuff is closed with sutures and attached to the uterosacral ligaments to prevent bowel prolapse. Finally, the peritoneum, muscle, fascia, and skin incision are closed.
Example 1: A 50-year-old woman with symptomatic uterine fibroids undergoes a total abdominal hysterectomy, including removal of the cervix, fallopian tubes, and ovaries., A 45-year-old woman with endometrial cancer undergoes a total abdominal hysterectomy with removal of the uterus and cervix., A 60-year-old woman with a prolapsed uterus undergoes a total abdominal hysterectomy with removal of the uterus, cervix, and fallopian tubes.
Documentation should include the indication for the hysterectomy, the specific organs removed (uterus, cervix, fallopian tubes, ovaries), operative details, and any complications encountered. If modifier 22 is used, the documentation must support the significant additional work performed.
- Revenue Code: P1E - MAJOR PROCEDURE - HYSTERECTOMY
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital