2025 CPT code 58263
(Active) Effective Date: N/A Revision Date: N/A Surgery - Vaginal Hysterectomy Surgery Feed
Vaginal hysterectomy for a uterus weighing 250 grams or less, with removal of fallopian tubes and/or ovaries, and repair of an enterocele.
Modifiers may be applicable depending on the circumstances of the procedure.Consult the CPT manual for appropriate modifier usage.
Medical necessity is established by documentation of symptoms warranting hysterectomy, such as menorrhagia, uterine prolapse, or other gynecologic conditions.The presence of an enterocele justifying repair should also be clearly documented.
The obstetrician-gynecologist or surgeon is responsible for performing the surgical procedure, which includes preoperative examination, administration of anesthesia, surgical removal of the uterus, fallopian tubes and/or ovaries, and repair of the enterocele. Post-operative care and follow-up are also the responsibility of the physician.
In simple words: This code covers a surgery to remove the uterus, fallopian tubes, and ovaries through the vagina.It also includes a repair of a hernia where part of the intestines bulge into the vagina.
This code represents a vaginal hysterectomy performed on a uterus weighing 250 grams or less.The procedure includes the removal of the fallopian tubes and/or ovaries and the surgical repair of an enterocele (prolapse of the small intestine into the vagina). The vaginal approach involves various steps such as incision of the cervix or posterior vaginal wall,incision and suturing of the uterosacral and cardinal ligaments, freeing the bladder, clamping and cutting the uterine arteries,elevating the broad ligament to cut the infundibulopelvic and round ligaments, removing the uterus, cervix, fallopian tubes, and ovaries, opening and repairing the enterocele sac, closing the enterocele sac and removing excess tissue, and closing the vaginal cuff.The procedure may include suspending the vaginal cuff to add additional support.
Example 1: A 45-year-old woman with menorrhagia and a small uterus undergoes a vaginal hysterectomy with bilateral salpingo-oophorectomy and enterocele repair.The uterus weighs 200 grams. Code 58263 is used., A 50-year-old woman presents with symptoms of uterine prolapse and an enterocele. She opts for a vaginal hysterectomy with removal of ovaries and enterocele repair.The uterus is less than 250 grams. Code 58263 is used., A 60-year-old woman with a history of pelvic organ prolapse undergoes a vaginal hysterectomy with removal of one ovary and enterocele repair. Her uterus weighs 230g. Code 58263 is appropriate.
Complete medical history, physical examination documenting the size of the uterus and presence of the enterocele, operative report detailing the procedure (including weight of the uterus, structures removed, and repair techniques used), pathology report if applicable, and informed consent.
** This code should only be used when all components of the procedure are performed.If additional procedures are performed, separate codes may be necessary. The weight of the uterus is crucial for proper code selection.
- Revenue Code: P1E (Major Procedure - Hysterectomy)
- Payment Status: Active
- Specialties:Obstetrics and Gynecology, Surgery
- Place of Service:Ambulatory Surgical Center, Hospital (Inpatient or Outpatient), Office