2025 CPT code 58260
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Vaginal hysterectomy for a uterus weighing 250 grams or less.
Modifiers may be applicable depending on the circumstances of the procedure.Consult current CPT guidelines and payer policies for appropriate modifier usage.Modifiers 51 (multiple procedures), 59 (distinct procedural service), and others may be applicable.
Medical necessity for a hysterectomy can include conditions such as menorrhagia, fibroids, endometriosis, prolapse, or pelvic pain not responsive to conservative management. Documentation should support the need for surgery based on the patient's specific clinical presentation.
The clinical responsibility lies with the surgeon performing the hysterectomy.This involves preoperative evaluation, surgical procedure execution, and postoperative care.Anesthesiology services are also typically involved.Pathology services are required for examination of the removed tissue.
In simple words: This code describes a surgery where the doctor removes the uterus and cervix through the vagina. This is only done for uteruses that are a small size (250 grams or less).
This code represents a vaginal hysterectomy, a surgical procedure involving the removal of the uterus and cervix through the vagina.The procedure is specifically for uteri weighing 250 grams or less. The surgeon typically uses a weighted speculum to hold the vaginal walls apart, incises the uterosacral and cardinal ligaments, frees the bladder, clamps and incises the uterine arteries, and elevates the broad ligament to release the uterus. The uterus and cervix are removed, and the vaginal cuff is sutured to provide support.
Example 1: A 45-year-old female presents with menorrhagia and fibroids.A vaginal hysterectomy (58260) is performed due to the small size of the uterus and patient preference for a less invasive approach., A 50-year-old female with a history of endometriosis undergoes a vaginal hysterectomy (58260) as part of a comprehensive treatment plan. The uterus is small and the procedure is chosen to avoid abdominal incision., A 38-year-old patient experiencing chronic pelvic pain due to uterine prolapse undergoes a vaginal hysterectomy (58260).The uterus was found to be small during the examination.
* Preoperative history and physical examination* Informed consent* Intraoperative notes documenting surgical approach, size and weight of the uterus, and any complications* Pathology report* Postoperative progress notes* Discharge summary
** Always ensure accurate documentation to support medical necessity and code selection.Consult with a coding specialist for complex cases or unusual circumstances.This information is for guidance only and does not constitute medical or billing advice.
- Revenue Code: P1E (Major Procedure - Hysterectomy)
- RVU: RVUs vary based on geographic location and other factors. Consult your local Medicare fee schedule for current values.
- Global Days: The global period is not specified for this code, and varies by payer and local practice.Check payer guidelines for details.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier is typically not applicable to this code, as it is a complete procedure itself.
- Fee Schedule: Historical fee schedule data is not included here. Contact your payer for that information.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center